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Serenethos Care Center, LLC

22822 Myrtle Street, Hayward, CA 94541 · For profit - Limited Liability company · 36 certified beds · (510) 537-4844 Medicare & Medicaid certified

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3 immediate-jeopardy citations
Insights

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

In its favor
  • a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • 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
  • inspectors cited 3 immediate-jeopardy problems — the most serious level
  • 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

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.

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

Location & what’s nearby

Hospital
1/5 CMS
Urgent care / clinic
Pharmacy
22331 Mission Blvd · (510) 581-6986 · Call to confirm hours
Grocery
370 Winton Ave · (510) 537-6909 · Call to confirm hours
Park
125 B St · (510) 881-6700 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5

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 improved from 1 to 5 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 rating5★
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 increased6.7%10.2%15.4%better
Long-stay residents who lose too much weight4.5%4.0%5.4%better
Long-stay residents with a catheter left in their bladder3.5%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.7%1.6%3.3%typical for the state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened2.5%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication0.9%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers6.0%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control3.8%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 table1.4%12.0%17.1%better
Long-stay hospitalizations per 1,000 resident days1.882.251.67worse
Long-stay outpatient ER visits per 1,000 resident days2.911.571.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

49.8% 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 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.8%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
0.16U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 94% of this home’s weekday level — it runs therapy at close to weekday levels right through 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.8%CMS range 30.0–69.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 7.0–16.010.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.261.02Oct 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

0.38
RN hours/ resident / day
1.09
LPN hours/ resident / day
2.53
Aide hours/ resident / day
3.99
Total nurse hours/ resident / day
0.34
RN hoursweekends
36.4%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 36 beds and averages 31.9 residents a day — about 89% 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 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 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 3.75 hrs/resident/day on weekends vs 4.09 on weekdays — 8% thinner on weekends. RN hours go from 0.40 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% 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

3
deficiencies at the latest standard inspection (2025-06-20)
11
at the previous standard inspection (2024-05-10)

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 13 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · Lcited before2022-12-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documents, and staff interviews, the facility failed to comply with federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time dietetic supervisor when the dietitian was not full time. Multiple issues were observed including the Food and Nutrition Services Department did not have a system in place to ensure the appropriate texture of food was prepared and served; the Food and Nutrition Supervisory staff did not ensure food safety and sanitation; and the Food and Nutrition Supervisory staff did not ensure staff were competent in performing necessary tasks to ensure food safety including ensuring the correct strength of sanitizer used to sanitize food-contact surfaces, and calibrating thermometers. In addition, when…

    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
  • Immediate jeopardy · J2022-12-16 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure nursing staff demonstrated appropriate competencies and skillsets necessary to care for residents' needs when physician prescribed food texture was not verified before serving food to residents, and when Certified Nursing Aide 3 (CNA 3) did not have the knowledge to identify the appropriate food texture in accordance with the diet order before serving food to a resident. These failures had the potential for one resident (Resident 34) out of a facility census of 35, to aspirate (to breath in or inhale foreign objects into the lungs. Aspiration can happen during choking but can also be silent, meaning there is no outward sign) and/or choke (severe difficulty breathing because of constricted or obstructed throat or lack of air) on food which could have resulted in death, when he was served a Regular texture diet (a diet that includes all textures of food including hard, tough, chewy, fibrous, stringy, dry, crispy, 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2022-12-16 · tag F0800 — isolated
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide a resident (Resident 34) a special dietary need as well as ensure Food and Nutrition Services had a system in place for preparing and serving the correct diet texture according to the physician's order when a regular texture diet (a diet that includes all textures of food including hard, tough, chewy, fibrous, stringy, dry, crispy, and crunchy; and intended for people without chewing and swallowing issues) was prepared for a resident (Resident 34) with prescribed modified texture Full Liquid diet (a diet made with fluids and foods that are normally liquid and/or turn to liquid when they are at room temperature). This failure had the potential for one resident (Resident 34) who had documented diagnoses showing swallowing difficulty, out of a facility census of 35, to aspirate (to breathe in or inhale foreign objects into the lungs. Aspiration can happen during choking but can also be silent, meaning there is no outward sign)…

    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 before2025-06-20 · tag F0801 — pattern
    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 interviews and record review, the facility failed to ensure that when it hired a part-time registered dietitian, the person designated to serve as the director of food and nutrition services met both the federal and/or state educational qualifications for the position. This failure had the potential for lack of competency and skill set necessary to carry out all the functions of the food services. Findings: During an interview on 6/17/25 at 10:01 a.m. with the Dietary Manager (DM), DM stated she was not the dietary supervisor for the facility. DM stated she covers for the sister facility, another building, but recently was orienting a new dietary supervisor who was on his way to the facility. During an interview on 6/17/25 at 10:24 a.m. with the Dietary Supervisor (DS), DS stated he was the DS. DS stated he worked at the facility as the Dietary Supervisor and Maintenance Director. DS stated his duties included checking the refrigerators and making sure supply of food items are done. DS provided a food handler certification. During an interview on 6/19/25 at 10:56 a.m. with…

    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 · D2025-06-20 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 the Preadmission Screening and Resident Review (PASRR) assessment for one of one sampled residents (Resident 1) was completed and coded accurately. This failure to accurately code Resident 1's PASRR assessments placed Resident 1 at risk to not receive care and services appropriate to his needs. Findings: During a review of Resident 1's admission Record, dated 6/19/25, the admission Record indicated Resident 1 has a diagnosis of major depressive disorder (MDD, a mental condition with a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts) and an eating disorder. During a review of the facility's provided letter titled Department of Health Care Services (DHCS) from Clinical Assurance Division, PASRR Section, Unable to complete PASRR II, dated 2/23/23, indicated Resident 1 had a positive PASRR I and PASRR II was not completed as Resident 1 was isolated as a health or safety precaution.…

    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 before2025-06-20 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 medication error rate did not exceed 5% for one out of four sampled residents (Resident 23) when nursing staff administered 4% lidocaine patch to Resident 23's knees on two separate days, instead of to the back as prescribed by the physician. These failures resulted in two medication errors being identified out of 27 opportunities during an observation of medication administration leading to a medication error rate of 7.41%. These deficient practices had the potential to result Resident 23 not having pain relief. Findings: During review of Resident 23's admission Record, dated 6/19/25, the admission Record indicated Resident 23 was admitted in September 2021 with a diagnosis of heart failure (when the heart does not pump as well as it should) and osteoarthritis (a breakdown of cartilage in joints, leading to pain and stiffness) with current pathological fracture (break) of the vertebrae (spine.) During a medication pass observation on 6/17/25 at 11:49 a.m., with Registered Nurse (RN) 1, RN 1…

    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 · E2024-05-10 · tag F0755 — failed to provide safe pharmacy services — pattern
    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

    Based on the observations and interviews conducted, it was concluded that the facility failed to provide pharmaceutical services to meet the needs of each resident. This conclusion was drawn due to the discovery of expired medications found in the medication storage areas. Expired medications can no longer be considered viable or safe to administer, and thus will not meet the needs of the residents who require effective and safe pharmaceutical care. Findings: During an observation on 5/7/24, several expired medications were found in the medication cart at 01:40 PM. The following expired medications were stored at room temperature and identified: *Insulin Lispro 100unit/ml for Resident 8 with an open date of 4/2/24 *Novolog pen 100unit/ml for Resident 8 with an opened date of 4/3/24 *Novolog 100unit/ml for Resident 17 with an opened date of 4/2/24 Based on stability studies insulin that had been opened and stored at room temperature can be stored up to 30 days. The above indicated that the open date exceeded 30 days. During an observation on 5/7/24 at 02:05 PM, revealed that there…

    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 · Ecited before2024-05-10 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, eight medication errors were observed out of twenty five opportunities for five of six residents, resulting in an error rate of 32%. Findings: A review on 5/7/24 of the facility policy titled Medication Administration General Guidelines. The policy indicates that during a medication pass, residents should be identified before administering medication using at least two distinct identifiers. These identifiers may include the resident's ID band, checking the photo attached to the medical record, or verifying the resident's ID with another nursing care center staff member. It is important to note that resident room numbers or physical locations should not be used as identifiers. In summary, the policy requires healthcare providers to confirm each resident's identity using two unique methods before administering medication, ensuring that the proper individuals receive their prescribed medications. During an…

    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 · Ecited before2024-05-10 · 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 facility document review, the facility failed to ensure food was stored and prepared in a safe and sanitary manner when: 1. A trash can in the dishwashing area was left uncovered. 2. The microwave was not clean. 3. Two packs of unopened corn Tortilla and one pack of opened Tortilla with a few left in the plastic bag, had expired. 4. A half full bag of premium golden light brown sugar with no received date and still in its paper sack. 5. A half full bag of salt still in its paper sack. These failures had the potential to result in contamination of food causing food borne illness for 30 residents who received food from the kitchen out of a facility census of 31. Findings: 1. During a concurrent observation and interview on 5/6/24 at 9:20 a.m. with Registered Dietician (RD), in the dishwashing area of the kitchen close to the back door, there was an uncovered gray round trash can that was almost filled up with trash. No staff was observed in the vicinity using the trash can. RD confirmed the trash was supposed to be covered with a lid. According 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 · E2024-05-10 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document reviews it was found that the facilities' Quality Assessment Performance Improvement (QAPI) program was ineffective. Despite its purpose to proactively identify and prevent medication administration errors, it fell short. This was evident during a medication pass observation conducted during the survey, which revealed a concerning 32% medication error rate (See F759). Findings: During observations, interviews, and document reviews conducted on 5/7/24, regarding medication administration practices at a nursing home facility. The following is a summary of medication errors that were identified: The facility's policy requires healthcare providers to identify residents using at least two distinct identifiers before administering medications. However, LVN 1 did not follow this protocol for three residents, relying solely on memory for identification. Additionally, the policy mandates offering water or an acceptable liquid with oral medications, but LVN 1 failed to do so for Resident 30, leading to difficulties in swallowing the medications.…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-10 · 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 ensure that staff followed the infection prevention and control policy and procedure (P&P) to prevent spread of infection for two of four sampled residents (Resident 30 and Resident 8) when: 1) The nebulization mask (a medical device used to deliver medication in the form of mist, which is inhaled into the lungs) of Resident 30 was not dated or labelled and left exposed in the bedside table drawer touching other personal items and the drawer surface with brownish dusty material. 2)The nebulization mask and CPAP mask (continuous positive airway pressure machine is used in the treatment of sleep apnea. This device delivers continuous pressurized air through tubing into a mask that is worn while sleeping) for Resident 8 was not dated or labelled and left exposed at the bedside table without protective covering, touching high touch surface area. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents. Findings: 1. During a record review of…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-10 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility document review, the facility failed to maintain the dish machine in safe operating condition when the temperature did not reach 120° (degrees) Fahrenheit (F). This failure had the potential for food preparation and food service utensils placed in the dish machine to not become fully cleaned and sanitized before being used. Findings: During an observation on 5/7/24 at 8:50 a.m. with [NAME] 1, [NAME] 1 loaded items into the dish machine and ran the machine. The dish machine was put through the wash and rinse cycle continuously two times and the wash and rinse cycle indicated 100° F on the temperature dial. [NAME] 1 stated it was 100° F, not reaching 120° F. [NAME] 1 ran the dish machine again through the wash and rinse cycle and in the last cycle, it indicated 115° F on the dial. [NAME] 1 stated it was supposed to reach 120° F. During an observation on 5/8/24 at 9:40 a.m., Dietary Supervisor (DS) ran the dish machine three times. The thermometer indicated 118° F. DS stated it was should have reached a minimum of 120° F. 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-10 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 80 square foot of space per resident for 8 residents who occupied 4 multi-bed bedrooms. This condition had the potential to result in lack of sufficient space for the provision of care both routine and emergency and for residents to have their personal belongings at bedside. Findings: During an observation on 5/7/24 at 2:00 p.m., the following rooms and corresponding square footage (sq. ft) per bed were identified: Room Activity Room Size Floor Area Capacity 1 Resident room [ROOM NUMBER].17x11.17 sq.ft 158.28 sq.ft 2 beds 5 Resident room [ROOM NUMBER].17x11.17 sq.ft 158.28 sq.ft 2 beds 6 Resident room [ROOM NUMBER].17x11.17 sq.ft 158.28 sq.ft 2 beds 12 Resident room [ROOM NUMBER].17x11.17 sq.ft 158.28 sq.ft 2 beds During random observations of care and services from 5/6/24 to 5/9/24, there was sufficient space for the provision of care for the residents in rooms 1, 5, 6, and 12. There was no heavy equipment kept in the rooms that…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · E2024-05-10 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure an effective pest control program when flies were observed in the kitchen. This failure had the potential to cause food borne illness. Findings: During two observations and concurrent interviews on 5/8/24 at 11:40 a.m. and 11:52 a.m. in the kitchen, two flies were observed flying around in the dry goods storage area; two flies were observed flying around in the food preparation and the dishwashing areas, close to the back door, there was one fly on the back door screen. RD confirmed there were five flies. RD stated it was their delivery day and they left the door open for delivery of food items. During an interview on 5/8/24 at 12:35 pm, RD stated there was no fly trap in the kitchen. During review of the facility's policy an procedures (P&P) titled Pest Control, dated 2008, the P&P indicated, our facility shall maintain an effective pest control program . This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. According to FDA Food Code 2022, 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-10 · tag F0550 — failed to protect resident dignity and rights — isolated
    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

    Based on observation, interview, and record review, the facility failed to maintain a working wall clock for one of one sampled resident (Resident 19) in her room. This failure placed Resident 19 at risk for confusion and disorientation. Findings: During a record review of Resident 19's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) Section C, dated 4/21/24, the record showed Resident 19's Brief Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score was 9 out of 15 indicating her cognition was moderately impaired. During a concurrent observation and interview on 5/6/24 at 9:47 a.m. with Resident 19, the wall clock in Resident 19's room showed the time was 6:15. Resident 19 stated she doesn't look at the clock in the room because it was not working and instead, she would look at the clock in the lobby to know what the time is. Resident 19 also stated she…

    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 before2024-05-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two (2) of four (4) sampled residents (Resident 20 and Resident 18) received proper grooming including nailcare when: 1. Resident 20 had long fingernails with black matter underneath 2. Resident 18 with contractures had long sharp nails digging into palms. This failure placed residents at risk for getting infections from lack of proper hygiene and injuring themselves with long fingernails and compromised physical and psychosocial wellbeing. Findings: 1. During a review of Resident 20's admission Record, printed on 5/9/24, the admission Record showed Resident 20 was admitted to the facility on [DATE]. During a record review of Resident 20's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 2/20/24, Resident 20's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-10 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to act upon consultant pharmacist's recommendations for clarification of indication of use for trihexyphenidyl (a medicine that improves muscle control and reduces stiffness in Parkinson's disease and other conditions) for one of five sampled residents (Resident 12). This deficient practice resulted in Resident 12 receiving unnecessary medication without proper indication and had the potential to negatively impact the resident's well-being. Findings: During a review of Resident 12's admission Record Report, printed on 5/9/24, the report indicated Resident 12 was admitted to the facility in March 2023. During a concurrent interview and record review on 5/9/24 at 12:55 p.m. with Registered Nurse (RN) 1, the Pharmacy Consultation Report for March 2024 and resident's current orders were reviewed. The Pharmacy Consultation Report, printed on 3/31/24, indicated the following comments: [Resident 12] is receiving trihexyphenidyl, since 3/3/23: for fall syndrome. The pharmacist recommendations read as: Please clarify the medical…

    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 · F2022-12-16 · tag F0802 — failed to prepare enough nourishing food — widespread
    Provide 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 facility document review, the facility failed to ensure the competency of staff when: 1. Staff did not know how to test the food-contact surface sanitizer; 2. Staff were not able to calibrate thermometers used to measure the temperature of food; 3. Staff did not know appropriate procedures for manual dishwashing; 4. Staff did not follow a recipe for the planned menu; and 5. Staff did not know the appropriate water temperature required for the dish machine. The failure to ensure staff had the competency to properly complete necessary tasks had the potential to result in food borne illness, as well as health complications for not receiving the nutrients intended by the planned menu, for 29 residents who received food from the kitchen out of a facility census of 35. Findings: 1. Review of the policy and procedure titled Quaternary Ammonium Log Policy dated 2018, showed the concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution. The food and nutrition worker will place the solution, from…

    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 before2022-12-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner when: 1. Meat was not thawed or stored properly; 2. Staff did not wash hands, use gloves, and use the handwashing sink properly; 3. Refrigerated food was not stored at an appropriate temperature; 4. Refrigerated food was moldy and not discarded by the use-by-date; 5. Equipment and utensils were found stored dirty and in poor condition; and 6. Storage cabinets, and drawers used for storing food and cooking utensils were not clean and in poor condition These failures had the potential to result in contamination of food and food borne illness for 29 residents who received food from the kitchen out of a facility census of 35. Findings: 1. Review of the policy and procedure titled Thawing [the process of a frozen substance becoming soft or liquid as a result of warming up] of Meats dated 2018, showed similar meat items could be thawed together but different…

    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 · F2022-12-16 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure the garbage dumpster bins located outside, had lids that tightly closed. This failure had the potential to attract pests to the facility and lead to pest related disease for 35 residents out of a facility census of 35. Findings: On 12/12/22 at 11:50 a.m., an observation and concurrent interview with Maintenance Supervisor 1 (MS 1), showed 3 large dumpster bins outside in the facility parking lot. MS 1 stated 1 bin was for recycling, the smallest bin was for kitchen garbage, and the last bin was for the rest of the facility garbage. All three bins had lids that were significantly bent so when the lids were closed there were multiple gaps between the bins and the lids. The gaps were large enough to easily fit a hand through. The bin for the kitchen was filled with plastic bags containing food waste, and were visible through the gaps. According to the 2017 Federal Food Code, receptacles for refuse used with materials containing food residue and used outside the food establishment shall be designed and constructed to have…

    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 before2022-12-16 · tag F0880 — failed to prevent and control infections — widespread
    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 observations, interviews, and record review, the facility failed to follow policies and procedures for infection control for 35 of 35 facility residents when: 1. Staff did not wear face masks appropriately and, 2. Facility did not have policy or procedure to monitor water for waterborne pathogens (disease causing micro-organisms which can grow in water). These failures had the potential result in respiratory or waterborne infection for facility residents. Findings: 1. During an observation on 12/12/22, at 9:19 a.m., Certified Nursing Assistant 2 (CNA 2) walked in the four-bed, shared room of Resident 12. CNA 2 wore a surgical face mask pulled below her chin exposing her nose and mouth, while three residents lay in bed in the room. During an observation on 12/12/22, at 9:44 a.m., Certified Nursing Assistant 3 (CNA 3) moved a mechanical lift into Resident 14's room, while wearing a surgical face mask with the nose uncovered. Resident 14 sat in a wheelchair in her room. During an observation on 12/12/22, at 12:05 p.m., Certified Nursing Assistant 4 (CNA 4) documented on 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-12-16 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility document review, the facility failed to: 1. maintain the dish machine in safe operating condition when the temperature did not reach 120 degrees Fahrenheit (F) . 2. ensure a food preparation sink drain had an airgap ((a gap of air created so a food equipment drainpipe is not directly connected to a drain containing sewage or wastewater). This failure to maintain the dish machine water temperature had the potential for food preparation and food service utensils placed in the dish machine to not become fully cleaned and then used; in addition, the failure to maintain an air-gap in the food preparation sink drain had the potential for the sink to become contaminated from waste water and then result in contamination of food, for 29 residents who received food from the kitchen out of a facility census of 35. Findings: 1. Review of the information plate, attached to the side of the dish machine showed the minimum rinse temperature for the machine was 120 degrees F. Review of the directions on the Dish Machine Temperature Log dated 2018 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 24) received fingernail trimming as needed. The failure to trim Resident 24's fingernails resulted in discomfort from the nails digging into the palms of both hands, which had contractures ((a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints and decreased mobility and function). This failure also had the potential to result in scratches, wounds, and infections from the long nails. Findings: A review of Resident 24's admission Record indicated Resident 24 was originally admitted to the facility in 2021, with diagnosis of quadriplegia (paralysis of entire body below the neck). A review of Resident 24's Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/23/22, indicated Resident 24 was usually able to understand others and was usually understood by others. The MDS indicated Resident 24 was totally dependent on one person to assist with activities of daily 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-16 · 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 observation, interview, and record review for one of four sampled residents (Resident 24), the facility failed to continuously assess the urine in the indwelling catheter tubing (a tube secured inside the bladder to drain urine into a bag outside the body). This failure could potentially result in delayed resolution of a possible urinary tract infection (UTI, an infection in any part of the urinary tract - kidneys, bladder, or urethra). Findings: A review of Resident 24's admission Record indicated Resident 24 was originally admitted to the facility in 2021, with a history of urinary tract infection (UTI) and a pressure ulcer (bed sore) on the right lower back. A review of Resident 24's Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/23/22, indicated the resident was usually able to understand others and was usually understood by others. The MDS indicated Resident 24 was totally dependent on one person for activities of daily living (ADL, mobility, eating, bathing, dressing, personal hygiene). The MDS also indicated Resident 24 had an indwelling…

    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
  • No harm found · Bcited before2022-12-16 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 and interview, the facility had four resident rooms (1, 5, 6, 12) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 12/12/22 at 11:00 a.m., the following rooms and corresponding square footage (sq. ft) per bed were identified: Room Activity Room Size Floor Area Capacity 1 Resident room [ROOM NUMBER].17x11.17 sq.ft 158.28 sq.ft 2 beds 5 Resident room [ROOM NUMBER].17x11.17 sq.ft 158.28 sq.ft 2 beds 6 Resident room [ROOM NUMBER].17x11.17 sq.ft 158.28 sq.ft 2 beds 12 Resident room [ROOM NUMBER].17x11.17 sq.ft 158.28 sq.ft 2 beds During random observations of care and services from 12/12/22 to 12/16/22, there was sufficient space for the provision of care for the residents in rooms 1, 5, 6, and 12. There was no heavy equipment…

    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.

    Environmental 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.

Who owns this facility

Owner / managerTypeRoleShareSince
SERENETHOS CARE CENTER, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 03/01/2018
BALDWIN, RONALDIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2018
XIE, QINGIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 03/01/2018
NG, ANDREWIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2018
DICKMAN WESTON GROUPOrganizationADP OF THE SNFsince 08/01/2019
HANSEN HUNTER LLCOrganizationADP OF THE SNFsince 08/01/2019

CMS files one row per role, so the 13 rows in the source record cover these 6 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.

$4.7M
Net patient revenuemost recent cost report
-3.5%
Operating marginrevenue minus expenses
$600K
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 14%Other / private 4%

About 83% 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 $600K paid to related parties — landlords or management companies under common ownership — equal to about 12% 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 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

$416per resident / day
operating cost
$12,652per month
≈ monthly operating cost
$402per 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 555905. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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