Hayward Healthcare & Wellness Center
1805 West Street, Hayward, CA 94545 · For profit - Individual · 99 certified beds · (510) 783-4811 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — 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 (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 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 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.6% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.9% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.4% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.8% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 15.8% | 9.8% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 6.5% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.5% | 4.3% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 4.6% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.4% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.8% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.6% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 16.1% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.98 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.91 | 1.57 | 1.80 | worse |
‡ 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.
42.2% 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 97 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 69.7% 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 66 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 0.51 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 42.2%CMS range 34.2–51.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 7.5–15.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 69.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 72.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 66.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 79.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 90.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 84.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 3.8–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.29 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 99 beds and averages 94.1 residents a day — about 95% occupied, or roughly 5 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 4.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 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 3.69 hrs/resident/day on weekends vs 4.21 on weekdays — 12% thinner on weekends. RN hours go from 0.55 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · Gcited before2026-04-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide adequate supervision and interventions to prevent elopement (leaving a facility or safe area unnoticed often due to confusion), for one of three sampled residents (Resident 1), with cognitive impairment (difficulties in one or more mental abilities such as memory, learning, language, attention, problem-solving, or decision-making that are more pronounced than expected for a person's age or education level) when Resident 1 was sent to a doctor's appointment without an escort despite needing an escort.This failure resulted in Resident 1 wandering off to the streets alone in cold and rainy weather for approximately three hours. Resident 1 was later located by Emergency Medical Services, (group of personnel who respond to medical emergencies in the community), approximately four blocks from the location of the appointment and was found to be wet and confused. Resident 1 was taken to an acute care hospital and received treatment. During a review of Resident 1's Face Sheet printed on 4/2/26, the Face Sheet 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.
- Potential for harm · D2025-02-19 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure medication was given according to the physician's order for three of three sampled residents (Resident 1, 2, 3) when: 1. Resident 1 did not receive the medication Gabapentin (used for nerve pain, which can be caused by different conditions, including diabetes.) 2. Resident 2 did not receive the medication Humalog insulin (helps control blood sugar levels after meals.) 3. Resident 3 did not receive the medication Hydralazine (used to treat high blood pressure.) This deficient practice had the potential for worsening of Resident 1, 2 and 3's clinical condition. Findings: 1. During a record review of Resident 1's undated admission Record , the admission Record printed on 2/6/25 indicated, Resident 1 was admitted in the facility on 6/29/16 with an admission diagnosis of diabetes mellitus (a condition that happens when blood sugar is too high). During a record review of Resident 1's Minimum Data Set (MDS- an assessment used to guide plan of care) dated 11/19/24, indicated Resident 1's Brief Interview of Mental Status…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-07-21 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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 staff were competent in appropriately testing and recording the surface sanitizer. This failure put 95 residents who received food from the kitchen at risk for illness from potentially ineffective sanitizing solution not being identified. Findings: During a concurrent observation, interview, and document review on 7/18/23 at 9:21 a.m. with DA 1 in the kitchen, stated she was responsible for filling the red buckets with sanitizer solution and recording the solution strength on the log. DA 1 filled a red bucket with a quaternary ammonia sanitizer solution from a hose located above the 2-compartment sink. She stated the solution was very hot. The temperature of the solution was measured with the surveyor's calibrated thermometer and it read 165 degrees Fahrenheit (F). DA 1 inserted a quaternary ammonia test strip into the red bucket that held a sanitizer solution. When she dipped the test strip into the solution, she immediately withdrew it. Then DA 1 held the strip to the color chart located inside the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. A resident food refrigerator was dirty, food was not labeled and dated, and the refrigerator temperatures were not monitored appropriately to keep food safe. 2. Staff did not follow appropriate hand hygiene procedures. 3. Stored equipment and utensils were dirty and ready for use. 4. The inside surface of the ice machine bin door was dirty. 5. Dry food storage bins were dirty and cracked. 6. Food storage areas were dirty. 7. Eggs and chicken were not stored appropriately. 8. A reach-in freezer door was in poor condition. 9. Plastic bags used to store food were not durable to protect food from contamination and adulteration (the action of making food poorer quality or unsafe by the addition of another substance). These failures put the facility at increased risk for food contamination and food borne illness for 95 residents who received food from the kitchen. Findings: 1. An observation and document review on 7/17/23 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-07-21 · tag F0813 — widespreadHave a policy regarding use and storage of foods brought to residents by family and other visitors.
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 staff followed the facility policy for food brought into the facility for residents by family and/or visitors and stored for residents up to 48 hours. This failure had the potential for a decreased consumption of food, as well as create an environment that was not home-like for 95 residents out of a facility census of 95. Findings: In an interview on 7/17/23 at 12:06 p.m., Licensed Vocational Nurse 2 (LVN 2) stated when food was brought in from a family or visitor, the facility could store the food up to 24 hours then discard the food. During an interview on 7/17/23 at 12:09 p.m. with Director of Nursing (DON), DON stated food brought from outside the facility for residents must be consumed or discarded the day it is brought in. During an interview on 7/17/23 at 12:15 p.m. with the Director of Staff Development (DSD), DSD stated she does the training and inservices; however, she did not do training related to the resident refrigerator. During a concurrent interview and document review on 7/19/23 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-21 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review the facility failed to a water management program to help reduce the risk for legionella and prevent spread of water borne pathogen growth. This failure had the potential to cause spread of water borne pathogen growth in the facility. Findings: During an interview on 7/19/23 at 11:06 a.m., with Administrator (Admin), Admin stated, facility had no water treatment program at this time. Admin could not provide documentation for facility's water treatment program to prevent legionalle and spread of water pathogen. Admin stated, she understood that water treatment program was required to be completed anuually and as needed to prevent spread of water pathogen. During a review of the facility's policy and procedure, titled, Water Management Program revised June 201, the policy and procedure indicated, The facility will develop and maintain a water management program to reduce Legionella and other waterborne pathogen growth and potential spread in facility.
- Potential for harm · E2023-07-21 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to provide palatable pureed bread for 11 residents on a pureed textured diet and palatable bread rolls for at least 10 residents on a regular textured diet. Serving food that was not palatable had the potential for 21 of 95 residents to consume a decreased amount of nutrients leading to weight loss and/or nutrient related medical complications. Findings: During a concurrent observation and interview on 7/18/23 at 11:30 a.m. with [NAME] 2 in the kitchen, tray line (process where food is plated according to order and placed on trays to serve) was observed. [NAME] 2 placed a scoop of a pureed white substance on the plates with diet orders for a pureed diet. [NAME] 2 stated, the white pureed substance being placed on puree trays was pureed bread. In addition, a large pan held bread rolls and [NAME] 2 placed bread rolls from the pans on plates for residents with a regular texture diet. More than 10 of the bread rolls in the pan were flat compared to the rest of the rolls which were more spherical shaped. 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.
- Potential for harm · E2023-07-21 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
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 Freezer #3 was maintained in good repair when the rubber gasket (a rubber piece that surrounds the inside perimeter of the freezer door to help keep the cold air in) around the interior perimeter of the door was torn and peeled away from the door. This failure had the potential for the freezer to not maintain appropriate temperatures that put the facility at risk for decreasing the quality of food stored in the freezer and/or affecting the safe storage of food leading to food borne illness for 95 residents who received food from the kitchen. Findings: During an observation on 7/17/23 at 10:05 a.m. during the initial kitchen tour, the rubber gaskets around the interior perimeter of both doors to Freezer #3 were torn and portions of the gasket were peeled away from the righthand side door. Review of the document titled Dietary Quality Control Review dated 5/31/23, showed the document was completed by Regional Registered Dietician (RRD) and indicated a torn gasket on Freezer #3. The corresponding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-21 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to thoroughly investigate allegation of abuse for one of two sampled residents ((Resident 75). Resident 75 alleged that a dark young male staff came to his room, knocked him on his head when he inquired about him coming to his room. The Administrator (Admin)/ designated representative did not interview Certified Nursing Assistant (CNA3) a male staff member that was assigned to provide care for Resident 75. This failure had the potential to place Resident 75 at risk for emotional distress, mistreatment or abuse. Findings: During a review of progress notes dated 5/29/23, progress notes indicated, Resident 75 reported to his daughter that a dark young staff came to his room around 3:00 p.m. on 5/27/23, knocked him on his head when he inquired about him coming to his room. During a review of Minimum Data Set (MDS), Resident assessment and care guide tool, dated 7/1/23, the MDS indicated, Resident 75 had clear speech able to make self understood and understand others. Resident 75's Brief Interview for Mental Status score was 08…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and maintain a care plan that was comprehensive and person-centered to meet the resident needs, for one resident (Resident 60) out of 26 sampled residents. This failure had the potential for one resident to not attain or maintain her highest practicable quality of life and/or receive quality care and services. Findings: Review of the policy and procedure titled Comprehensive Person-Centered Care Planning revised November 2018, showed it is the policy of the facility to provide person-centered, comprehensive care that reflects best practice standards for meeting health needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. Procedures include creating and updating a comprehensive care plan based on the assessed needs of the resident. A Record review showed Resident 60 was a [AGE] year-old female, was admitted on [DATE] with a diagnoses including but not limited to malignant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-21 · tag F0659 — isolatedProvide care by qualified persons according to each resident's written plan of care.
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 the comprehensive plan of care for one resident (Resident 60) out of 26 sampled residents, was written by a qualified staff. This failure placed one resident at risk for not attaining or maintaining her highest practicable quality of life and/or receive quality care and services. Findings: According to the California Code, Business and Professions Code, a registered dietitian may perform nutritional assessments and initiate nutritional interventions within parameters of the prescribed diet order. The dietitian shall collaborate with a multidisciplinary team, which shall include the treating physician and the registered nurse, in developing the patient's nutrition care plan. The services described may be termed medical nutrition therapy. Review of the job description titled Registered Dietitian dated 11/27/17, showed the Registered Dietitian (RD) was responsible for evaluating the Medical Nutrition Therapy needs of the residents and implementing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2023-07-21 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
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 provide assistance needed for toenail care as ordered by the physician for one (Resident 54) of two sampled residents when Resident 54 had crooked ingrown toenails (a condition in which the corner or side of a toenail grows into the flesh). This failure had the potential for residents prone to injury and infection Findings: During an observation on 7/17/23 at 12:05 p.m., Resident 54 was seated up in bed in her room. Resident 54 had crooked ingrown toenails During a review of Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 5/26/23, the MDS indicated, Resident 54's Basic Interview of Mental status (BIMS) score was 15 (meaning cognitively intact). Resident 54 had clear speech. had difficulty communicating some words or finishing thoughts but is able if prompted or given time to respond. Resident 54 needed extensive assistance with personal hygiene, including combing hair, brushing teeth, washing /drying face and hands. Resident 54's diagnoses included cerebrovascular accident (CVA)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one (Resident 41) of six sampled resident received treatment services to address functional limitation in range of motion when; the Rehabilitation Department did not provide Resident 41 Physical and Occupational therapy {PT/OT} as ordered by the physician. {Physical Therapy- the treatment of disease, injury, or deformity by physical methods such as massages, heat treatment, and exercise rather than by drugs or surgery}. {Occupational Therapy- a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life}. This failure had the potential to cause Resident 41 decline in mobility, range of motion, difficulty with transfers, turning and repositioning. Findings: During the Resident Council Meeting on 7/18/23 at 11:05 a.m., Resident 41 stated, she had not received any form of exercise since her admission to the facility on 5/31/22. Resident 41 stated,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to assess and evaluate one (Resident 54) of three sampled residents for an appropriate size wheelchair when; Director of Rehabilitation (DOR1) provided Resident 54 a wheel chair that was small and tight. Resident 54 sustained a bruise (an injury appearing as an area of discolored skin on the body caused by a blow or impact rupturing underlying blood vessels) to right lateral thigh. This failure caused Resident 54 bruise to her right lateral thigh and potential to cause wheelchair bound residents injuries. Findings: During a concurrent observation and interview on 7/17/23 at 12:05 p.m., Resident 54 was seated up in bed in her room. Resident 54 showed surveyor the bruise on her right lateral thigh. Resident 54 had bruised skin discoloration area on the right lateral thigh. Resident 54's son (FM2) was at her bedside also. FM2 stated, the wheelchair assigned to Resident 54 was small for her and had caused her injury to right lateral thigh. FM2 stated, he had requested a replacement of wheelchair from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-21 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide dental services to meet resident's needs for one of 22 sampled residents (Resident 57) when referral to outside dentist was not acted upon. This failure had the potential to result in Resident 57 to have tooth infection, difficulty eating and weight loss. Findings: During a review of Resident 57's admission record, the admission record indicated Resident 57 was admitted to the facility on [DATE], with a diagnosis of Diabetes Mellitus (an illness when the blood sugar is too high). During an interview on 7/16/23, at 10:16 a.m., with Resident 57, Resident 57 stated, the facility did not take care of her teeth and let them decay. Resident 57 stated, she did not want her teeth to be extracted. During a review of Resident 57's Social Services Director's (SSD) progress notes, dated 8/31/22, the progress notes indicated, Resident 57 was seen by the facility's visiting dentist (a dentist who provides dental examination to residents living…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-21 · tag F0806 — failed to honor food preferences — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to provide food preferences for one resident (Resident 60). This failure had the potential to result decreased nutrient intake leading to unplanned weight loss and nutritional related medical complications for one resident out of 26 sampled residents. Findings: Review of the policy and procedure titled Dietary Profile and Resident Preference Interview revised 4/21/22, showed The Dietary Manager will complete a Dietary Profile for residents to reflect current nutritional needs and food preferences . The purpose of the policy was to ensure residents were properly evaluated for dietary needs on an ongoing basis. The procedures included but were not limited to: the dietary department will provide residents with meals consistent with their preferences. If a preferred item is not available, a suitable substitute should be provided, and the Dietary Manager may update food preferences as often as necessary. According to the National Cancer Institute cancer treatments may lower appetite or change the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-21 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure 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 facility document review, the facility failed to provide physician ordered snacks for one resident (Resident 60). This failure had the potential to result in increased weight loss and nutritional related medical complications for 1 resident out of 26 sampled residents. Findings: Review of the policy and procedure titled Nourishment and Snacks revised 4/1/2014, showed nourishments will be provided to offer nutritional support. The provision of nourishments requires a physician's order. Residents who may receive snacks include, but not limited to, residents who are under weight or have experienced weight loss and residents with poor intake. A Record review showed Resident 60 was a [AGE] year-old female, was admitted on [DATE] with a diagnoses including but not limited to malignant neoplasm (cancer) of the endometrium (membrane lining the uterus), type 2 diabetes (a condition that affects the way the body processes blood sugar), adult failure to thrive (a syndrome of weight…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-21 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the outside garbage storage area was maintained in a sanitary condition when refuse, bones, and dark liquid waste was found on the ground surrounding the garbage receptacles. This failure put the facility at increased risk for attracting pests and potentially causing pest related disease in 95 of 95 residents. Findings: A concurrent observation and interview on 7/17/23 at 12:40 p.m. with Maintenance Assistant (MA), showed the outside garbage area included garbage, green waste, and recycling dumpsters. On the ground, just to the left of the garbage dumpster were bones and debris such as discarded plastic bottles containing fluid, latex gloves, food packaging and paper napkins. There was also a significant amount of dark liquid waste on the ground in front of the garbage and green waste dumpsters. The dark liquid came from the green waste dumpster and had paper debris sticking to it such as straw wrappers. In addition there was a significant amount of flies and ants surrounding the liquid and the green…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-10-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices when there were multiple plastic wares stored wet inside the kitchen cupboard. These deficient practices had the potential to result in foodborne illnesses. Findings: During the initial tour observation of the kitchen and concurrent interview with the Dietary Aide 1 (DA 1) on 10/7/19 at 8:04 a.m., multiple stacked pink-colored plastic cups and mini trays, and blue-colored water pitcher lids were stored wet inside the cupboard. DA 1 stated dishes needed to be fully air-dried before they were stored in the cupboard. In an interview with the Dietary Services Supervisor (DSS) on 10/8/19 at 11:16 a.m., DSS stated dishes should be racked loosely and air-dried completely for safer storage to prevent microorganism growth. Review of the undated facility policy and procedure titled, Dish Washing indicated that .Dishes are to be racked loosely without overlapping .Dishes are to be air dried in racks before stacking and storing
- Potential for harm · D2019-10-10 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of 25 (Resident 5) sampled residents, the facility failed to inform and provide information to the residents and/or the resident representatives, the option to formulate an advance directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make a decision for themselves because of illness or incapacity). This failure had the potential to result in delay of the treatment directions to healthcare providers regarding Resident 5's medical care. Findings: Review of the Resident Face Sheet, printed 10/8/19, indicated Resident 5 was readmitted to the facility on [DATE]. During a review of the medical record for Resident 5, the Physician Orders for Life-Sustaining Treatment (POLST) form, signed 11/4/18, indicated Section D - Information and Signatures regarding Advance Directives was left unanswered. Review of Resident 5's significant change in status Minimum Data Set (MDS - an assessment tool used to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-10 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, for one of 25 sampled residents (Resident 73), the facility failed to provide care and services for feeding tubes. Certified Nursing Assistant (CNA) 2 lowered Resident 73's head of the bed to the flat position to provide personal hygiene care while Resident 73's enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) was being administered through the G-Tube (Gastrostomy Tube - a tube inserted through the belly that brings nutrition directly to the stomach) via a pump. For Resident 73, this failure had the potential to result in aspiration (inhalation) of the feeding formula and lead to aspiration pneumonia (a lung infection that develops after aspirating food, liquid, or vomit into the lungs). Findings: Review of Resident 73's Minimum Data Set (MDS - an assessment tool used to guide care) indicated Resident 73 was severely impaired of cognitive skills, required one to two-person assistance for dressing and personal hygiene, and had a feeding tube for nutrition.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-11-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to ensure on (Resident 4) of 21 sampled residents received assistance with activities of daily living (ADL - e.g. personal hygiene) when Resident 4 (a female) did not receive assistance personal grooming and had a full beard. This failure resulted in Resident 4 feeling bad about herself. Findings: Review of Resident 4's Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 12/27/17, indicated Resident 4 mental status was severely impaired and required the assistance of one staff person with ADLs. In an observation on 11/27/18, at 11:03 a.m., Resident 4 had a full beard. During an interview on 11/27/18, at 11:03 a.m., Certified Nursing Assistant (CNA) 1 stated Resident 4 refused shaving. In an observation on 11/28/18, at 9:30 a.m., Resident 4 was clean shaven and smiling. Resident 4 stated that now she felt pretty. In an observation on 11/28/18, at 10:30 a.m., Resident 4 was still smiling about being clean shaven and was co-operating with facility staff.
- Potential for harm · D2018-11-29 · tag F0697 — failed to manage pain — isolatedProvide 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 observation, interview and record review, for two of 21 sampled residents, the facility failed to implement their Pain Management policy and procedure when Residents 6 and 243 experienced pain and Licensed Vocational Nurse (LVN) 1 did not assess the Residents for pain using the zero to 10 pain scale (zero being no pain and 10 being the worst pain). This failure had the potential to result in Resident 6 and Resident 243's pain to be incompletely relieved or managed. Findings: 1. Review of Resident 6's Facesheet, printed 11/28/18, indicated Resident 6 was admitted to the facility with diagnoses that included rheumatoid arthritis (a chronic inflammatory disorder in which the body's immune system attacks its own tissue, including joints, causing pain and swelling). Review of Resident 6's Minimum Data Set (MDS - a resident assessment too used to guide care), dated 12/1/17, indicated Resident 6 was able to identify the correct day, month, year, and could recall words presented to her. Resident 6 had clear speech and could express ideas and wants and had clear comprehension of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2018-11-29 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, for one of 21 sampled residents (Resident 69), the facility failed to implement their Dressings - Application to ensure cleanliness policy and procedure when Licensed Vocational Nurse (LVN) 2 did not re-clean Resident 69's sacral (lower back) pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) after Resident 69 rolled onto the open wound during a dressing change. This failure had the potential to result in infection. Findings: Review of Resident 69's Facesheet, printed 11/28/18, indicated Resident 69 was admitted to the facility with diagnoses that included muscle weakness. Review of Resident 69's Physician's Telephone Orders, dated 10/31/18, indicated Resident 69 had a sacral pressure injury that required cleaning and dressing changes, daily and as needed, by the facility's licensed nurses. Review of Resident 69's Care Plan, Pressure Injury, dated 9/16/18, indicated Resident 69's pressure injury was to be free of signs and symptoms of infection. In an observation on 11/29/18,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SOL HEALTHCARE — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.6 | -0.6 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 3 of 5 | 3.4 | -0.4 vs chain |
| Quality measures | 3 of 5 | 3.4 | -0.4 vs chain |
The other 7 homes this chain runs (chain average 2.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SOL HEALTHCARE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 99% | since 02/04/2010 |
| MAJER, SOL | Individual | DIRECT OWNERSHIP INTEREST | — | since 02/04/2010 |
| ROCKPORT ADMINISTRATIVE SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/04/2010 |
| DATT, LALEEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/18/2023 |
| NG, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| RECHNITZ, SHLOMO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2020 |
| ERETZ HAYWARD PROPERTIES LLC | Organization | ADP OF THE SNF | — | since 06/01/2021 |
CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 73% 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 $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055874. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-07-21, 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.