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Vista Post Acute

3269 D Street, Hayward, CA 94541 · For profit - Limited Liability company · 71 certified beds · (510) 537-6700 Medicare & Medicaid certified

Call the home — (510) 537-6700 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (28) — 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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1866 B St · (510) 300-3800 · Call to confirm hours
Pharmacy
1652 B St · (510) 200-9984 · Call to confirm hours
Grocery
22660 Vermont St · (510) 881-8020 · Call to confirm hours
Park
Lakeridge Ave · (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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased2.4%10.2%15.4%better
Long-stay residents who lose too much weight3.7%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.7%0.8%0.9%better
Long-stay residents with a urinary tract infection1.4%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 injury1.8%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened1.8%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication5.2%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers2.5%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control1.8%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 table12.3%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission30.3%23.0%22.6%worse
Short-stay residents with an outpatient ER visit21.2%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.822.251.67worse
Long-stay outpatient ER visits per 1,000 resident days4.641.571.80worse

* 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.

36.9% 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 85 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

36.9%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
52.4%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 52.4% 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 42 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNF36.9%CMS range 26.9–51.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 7.5–15.210.7%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 discharge52.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge50.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge33.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 discharge91.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.8%CMS range 5.4–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.331.02Oct 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

0.52
RN hours/ resident / day
0.89
LPN hours/ resident / day
2.56
Aide hours/ resident / day
3.97
Total nurse hours/ resident / day
0.53
RN hoursweekends
28.0%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 71 beds and averages 68.9 residents a day — about 97% occupied, or roughly 2 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 3.97 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 2.56 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 3.50 hrs/resident/day on weekends vs 4.16 on weekdays — 16% thinner on weekends. RN hours go from 0.51 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 28% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2025-01-30)
11
at the previous standard inspection (2023-09-14)

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.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Ecited before2025-01-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility had a medication error rate of 13.79% when four medication errors occurred out of 29 opportunities during the medication administration observation for four out of nine residents (Residents 3, 8, 10, and 37). Resident 37 did not receive one medication as scheduled; Resident 8 received insulin with incorrect priming; and Residents 3 and 10 did not receive one medication as prescribed. The failures resulted in the residents not receiving the medications as prescribed and had the potential for complications of their medical conditions (such as high/low blood sugar or blood pressure). Findings: 1. During the medication administration observation on 1/27/25 at 10:02 a.m., Licensed Vocational Nurse B (LVN B) was observed preparing one medication, doxazosin (a medication to treat high blood pressure) for Resident 37. LVN B stated, I don't have chlorhexidine [an antiseptic mouthwash with broad-spectrum antimicrobial activity against bacteria, viruses, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-30 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in a clean environment, within standards for safety when: 1. Floor drains were not maintained clean; 2. Kitchen tile floors were not clean and were not maintained in good repair; 3. Kitchen wall had an opening in the wall around the drain; 4. Kitchen backsplash, where dishes were cleaned, had food and black substance buildup; 5. A kitchen cleaning schedule was not maintained according to facility policy; 6. Frozen meat did not have date received, date placed in freezer, use by date, and expiration date; 7. Produce and food were not labeled with use by date and were not rotated with FIFO, First in-First out per facility policy; 8. Food in refrigerator had expired. These failures had the potential to result in contamination of food leading to food borne illness, for 69 residents who resided in the facility. Findings: During an observation on 1/27/2025, at 9:30 a.m., in the kitchen, a drain cover over the floor drain in the middle of the dish room was not secured with tile,…

    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 before2025-01-30 · 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 observe proper infection control practices when: 1. A nursing staff failed to perform hand hygiene after touching potentially contaminated surfaces during the medication administration; 2. A nursing staff touched and opened two medication capsules with bare hands; 3. A nursing staff failed to observe the enhanced barrier precautions (EBP) as per facility policy and procedures (P&P) for two residents (Residents 37 and 61) during the medication administration; These failures had the potential for Residents 37, 54 and 61 to be placed at risk for infections. Findings: 1. During a medication administration observation with Registered Nurse (RN) A on 1/27/25, at 9:29 a.m., RN A was observed preparing two medications, which was put in a small medication cup, for Resident 54. On 1/27/25, at 9:40 a.m., RN A placed the medication cup along with a cup of juice in a medication tray, brought it to Resident 54's bedside, and placed it on the resident's table. Then, with her gloved hands, she moved the resident's wheel…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure 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, the facility failed to provide care according to facility policy and procedures (P&P) when the nursing staff did not check the tube placement and/or residual volume before medication administration for three of three residents (Residents 10, 37, and 61) who were receiving medications via the gastrostomy tube (aka G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). The failure had the potential for complications related to enteral feeding such as aspiration (foreign material into the lungs) due to undetected tube displacement, nausea, vomiting, etc. Findings: a. During a medication administration observation on 1/27/25 at 10:02 a.m., Licensed Vocational Nurse (LVN) B was observed preparing a medication, doxazosin (medication to treat high blood pressure), for Resident 37. She crushed and diluted the medication with water. On 1/27/25 at 10:08 a.m., at the resident's bedside, LVN B was observed attaching the 60-milliliter (mL, unit of measurement) syringe to the resident's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure discontinued and unused controlled medications (medications that can be easily abused and are under strict government control) for three residents (65, 123, and 174) were promptly removed from one of three inspected medication carts. The failure had the potential for medication errors or loss/abuse of controlled medications. Findings: 1. During an inspection of the Station 1 medication cart with Licensed Vocational Nurse (LVN D) on 1/27/25 at 11:06 a.m., two opened bottles, one 180-milliliters (mL) and one 120-mL, of morphine (a potent narcotic medication for pain) 2 milligrams (mg) per mL for Resident 174 were identified in the locked compartment of the cart. The Controlled Drug Record (CDR or Count Sheet, an inventory sheet documenting the medication, count, date, time, amount given, the amount left, and the signature of the user) for each bottle was wrapped around the bottle with a rubber band. LVN D stated each bottle has zero count left, meaning the count on the CDR had zero (0) amount remaining…

    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 · D2025-01-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure one of 20 sampled residents (Resident 47) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior). Resident 47 received quetiapine (Seroquel, an antipsychotic medication) for delusion (fixed, false beliefs that conflict with reality) without documented evidence of delusional symptoms, and without demonstration how these symptoms caused harm to the resident/others or caused significant distress to the resident. The failure had the potential for the resident to receive the antipsychotic medication unnecessarily, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. Findings: A review of Resident 47's clinical record indicated he was admitted to the facility with diagnoses including unspecified dementia (general term that describes a group of symptoms,…

    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 · D2024-12-13 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is 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 observation, interview and record review, the facility failed to provide meal assistance for one of five sampled residents ' (Resident 1) when staff did not reposition Resident 1 higher in bed and did not assist in setup of meal tray for 30 minutes during dinner. This failure prevented Resident 1 from finishing dinner because Resident 1 was in an uncomfortable position and could not reach or open food items on the meal tray, which had the potential for weight loss and low blood sugar. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of fall, fracture of lumbar vertebra (lower back bone), rib fractures, muscle weakness, and diabetes (long-term disease in which the body cannot regulate the amount of sugar in the blood). During a record review of Resident 1 ' s physician order set titled, Order Summary Report, dated 10/29/24, the order set indicated Resident 1 had an order for [Carbohydrate control] diet .assist with meal,…

    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 · Ecited before2023-09-14 · 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 observation, interview, and record review, the facility had a medication error rate of 15.63% when five medication errors occurred out of 32 opportunities during the medication administration observation for three of five residents (Residents 11, 20, and 36). Resident 20 received a corticosteroid (aka steroid) oral inhaler without rinsing her mouth with water afterwards; Resident 11 did not receive two medications as scheduled; and Resident 36 did not receive two medications as prescribed. The failures had the potential for the residents not receiving the full therapeutic effect of medications, or adverse affects, compromising their health. Findings: 1. During a medication administration observation on 9/11/23 at 8:05 a.m., Registered Nurse (RN ) 2 was observed preparing 8 medications for Resident 20 including an oral inhaler containing a combination of budesonide and formoterol (budesonide belongs to a class of drugs known as corticosteroids. It works by reducing the irritation and swelling of the airways. Formoterol belongs to the class of drugs known as long-acting beta…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-14 · 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 protect the right of privacy for one of 23 sampled residents (Residents 52) when personal care instructions were posted on the walls of the resident's shared room. This failure had the potential to affect Resident 52's sense of self-worth and self-respect due to the public display of personal care information. Findings: During an observation on 9/11/23, at 8:06 a.m., inside Resident 52's shared room, three signs without privacy covers (two signs stated, Please use wipes when cleaning him. Thank you. and one sign stated, Please use the wipes to wipe the Resident instead of the towel. Thank you!), were posted on the walls (by Resident 52's headboard, to the left side of Resident 52's bed, and across the room, taped to the closet of Resident 52). The signs listed were specific personal care instructions for Resident 52. During an interview on 9/12/23, at 11:45 a.m., with the Director of Nursing (DON), the DON stated because it was the family of Resident 52 who posted the signs in the shared room, DON thought it…

    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 before2023-09-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living 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 provide an orderly and homelike environment for two of 23 sampled residents (Resident 52 and resident 119), when an old, uncovered sign that showed the name of the previous resident (Resident 42) was not removed from the shared room currently occupied by Resident 52 and Resident 119. This failure had the potential to affect Resident 52 and Resident 119's well-being and cause mental confusion in a setting meant to be their home. Findings: During a concurrent observation and interview on 9/11/23, at 8:06 a.m., with Certified Nursing Assistant 2 (CNA 2), an uncovered typewritten sign (stating, Family will do laundry. followed by a handwritten name of Resident 42) was posted on the closet door visible from both Resident 52 and Resident 119's beds. CNA 2 stated Resident 42's family posted the uncovered sign which was not removed when Resident 42 was sent out to the hospital then later discharged from the facility. CNA 2 stated the old sign should have been removed because it didn't belong to the current residents…

    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
Show the remaining 18 citations
  • Potential for harm · D2023-09-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to verify the physician's wound care treatment order for one of 23 sampled residents (Resident 29) prior to rendering wound treatment. This failure had the potential to not promote the healing of Resident 29's wounds. Findings: A review of the face sheet for Resident 29, indicated Resident 29 was admitted to the facility on [DATE]. During a review of Resident 29's Surgical Consult, dated 9/6/23, the Surgical Consult indicated, Resident 29 had left foot wounds caused by venous stasis disease (veins cannot send the blood from the legs back to the heart). During a concurrent observation and interview on 9/12/23, at 1:29 p.m., with Infection Preventionist (IP), in Resident 29's room, IP administered Resident 29's left foot wound care without checking the physician's wound care order. IP stated the risk of doing the wound treatment without checking the physician's order was giving the wrong wound care to Resident 29. During an interview on…

    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 · D2023-09-14 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot 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 observation, interview and record review, the facility failed to ensure one of 23 sampled residents (14) was referred and was provided podiatry services. This deficient practice resulted in Resident 14 to have pain and at risk of injury because of her long toenails. Findings: A review of Resident 14's face sheet, dated 8/14/23, indicated Resident 14 was admitted to the facility on [DATE] with a diagnosis of peripheral vascular disease (narrowing of the tubes that carry blood to the different parts of the body which can cause poor blood flow to the legs). A review of Resident 14's Minimum Data Set (MDS, a comprehensive assessment tool to guide care), dated 7/5/23, indicated Brief Interview for Mental Status (BIMS, a screening tool to identify resident's cognitive status) score of 13, indicating Resident 14 had intact cognitive function. During a concurrent observation and interview on 9/11/23, at 9:50 a.m., with Resident 14, in Resident 14's room, Resident 14 had long toenails. Resident 14 stated all her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide a safe environment for one of 23 sampled residents (Resident 27) when Certified Nursing Assistant 1 (CNA 1) transferred Resident 27 from bed to shower chair using a mechanical lift (a mechanical device used to assist with transfer and movement of residents who required support for mobility beyond the manual support provided by caregivers alone) by himself and without assistance. This failure had the potential to result in serious avoidable resident injury. Findings: A review of Resident 27's admission Record, dated 9/12/23, indicated Resident 27 was admitted to the facility in 2021 with diagnoses of Parkinson's disease (a chronic disorder that affects movement causing tremors, stiffness, and loss of balance) and other abnormalities of gait and mobility. A review of Resident 27's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 6/13/23, indicated resident required extensive assist with 2 or more person-transfer from bed to chair. A review of Resident 27's Care Plan, dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-14 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pain-relieving medication to one of 23 sampled residents (Resident 120) before a Stage 4 pressure ulcer (severe tissue damage that extends to muscles, bones and/or tendons) wound dressing change was rendered. This failure resulted in Resident 120's avoidable, unnecessary pain and discomfort during Resident 120's wound treatment which affected Resident 120's ability to maintain his highest practicable physical, mental, and psychosocial well-being. Findings: A review of Resident 120's admission Record, dated 9/14/23, indicated resident was admitted to the facility on [DATE] with diagnosis of Stage 4 pressure ulcer of sacral region. A review of Resident 120's clinical record titled, Admit/Readmit Assessment, dated 9/12/23, indicated Resident 120 had moderately impaired cognition. Resident 120's Pain Assessment indicated resident verbalized and/or exhibited non-verbal symptoms of pain and had a numeric pain scale (pain rate where 0 is…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-14 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse and addiction) and safe use of emergency medications when: 1. Random controlled medication use audit for three of three sampled residents (Residents 53, 59, and 62) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications; and 2. Three of nine emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were not replaced timely after being opened or expired. The failure had the potential for not having emergency medications/supply on hand when needed or expired medications given to the residents. Findings: 1. During 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-14 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) inspect the emergency medication kits (e-kits) on a monthly basis in accordance with the facility policy and procedures (P&P). Also, the CP failed to identify and report to the facility medication irregularities during the monthly medication regimen review (MRR) for two of 23 sampled residents (14 and 27). The failures resulted in opened and expired e-kits not being replaced timely for resident use; and undetected medication irregularities had the potential for residents not achieving highest therapeutic outcomes. Findings: 1. During a visit to Station 2 Medication Room with Registered Nurse 1 (RN 1) on [DATE] at 9:44 a.m., three expired e-kits were identified in a locked cabinet. The CIII-CV E-kit (kit containing Scheduled 3 to Schedule 5 controlled medications) had the expiration date of 4/2023. Two medications, the lorazepam and temazepam (medications to treat agitation and anxiety) tablets, inside…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-14 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 two of 23 sampled residents (Residents 10 and 27) and a non-sampled resident (Resident 39) were free from a significant medication error when they received insulin (medication to lower blood sugar) past the discard (expiration) date. This deficient practice had the potential for ineffective use of the insulin, which would result in uncontrolled high blood sugar for the residents. Findings: 1. On 9/11/23 at 10:18 a.m., an inspection of Medication Cart #2 with Registered Nurse 1 (RN 1) revealed the following: - A Basaglar Kwikpen (a pre-filled insulin pen containing a long-acting insulin called insulin glargine) for Resident 27, which had a written open date of 8/3/23. - A Lantus SoloStar (a pre-filled insulin pen containing insulin glargine) for Resident 39, which had a written open date of 8/10/23. On 9/11/23 at 10:45 a.m., a review of the pharmacy label on both insulin pens with RN 1 indicated to discard 28 days after opening. RN 1 confirmed the insulin pen for Resident 27 would have expired on 9/1/23…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-14 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure three of nine emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) did not expire; expired insulin (medication to lower blood sugar) prefilled pens were removed from the medication carts for two of two medication carts inspected; and an opened multi-dose vial had an open date in one of two medication refrigerators inspected. The failure resulted in insulin pens given past the expiration date; and the potential for residents to receive expired medications which would result in unsafe and ineffective use. Findings: 1. During a visit to Station 2 Medication Room with Registered Nurse 1 (RN 1) on 9/11/23 at 9:44 a.m., three expired e-kits were identified. The CIII-CV E-kit (kit containing Scheduled 3 to Schedule 5 controlled medications) had the expiration date of 4/2023. Two medications, the lorazepam and temazepam (medications to treat agitation and anxiety) tablets, inside the kit had the expiration date of 4/2023. Two IV Supply e-kits (kit…

    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 before2021-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to keep two of three treatment carts (a portable cart containing supplies needed for wound care) locked when not in the view of a licensed nurse. This failure had the potential to result in injury to residents, staff, or visitors from unauthorized use of injection needles, scissors, and suture supplies (needles and surgical thread used to sew wounds closed). Findings: During an observation on 4/26/21 at 11 a.m., at nursing station 3, on the ground floor of the facility, was an unlocked, unsupervised treatment cart. The second drawer of the cart was unlocked and contained surgical scissors, injection needles, and suture materials. There was no licensed nurse present at nursing station 3, or on the ground floor. Certified Nursing Assistant 2 (CNA 2) was the only nursing staff present on the ground floor and was not in view from the nursing station. During a continual observation on 4/26/21 from 11 a.m. to 12:25 p.m., the treatment cart was unlocked and unsupervised. During an interview on 4/26/21 at 11:17 a.m.,…

    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 · Ecited before2021-04-29 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure to drugs used to control pain and anxiety were labeled with the correct physician orders for 8 of 11 sampled residents (Residents 51, 106, 52A, 52B, 10, 308, 16, 24, and 7). These failures had the potential to result in Residents 51, 106, 52A, 52B, 10, 308, 16, 24, or 7 receiving incorrect medication doses with resultant overdosage or underdosage causing oversedation or ineffective treatment of pain and/or anxiety. Findings: During an observation on 04/27/21 at 12:16 p.m., Licensed Vocational Nurse 1 (LVN 1) picked up Resident 51's multidose medication package labeled Hydrocodone-Acetaminophen 5-325 milligrams (a combination pain reducing medication subject to government regulations due to five milligrams of an opium-based ingredient with 325 milligrams of acetaminophen). The label indicated, 1 tablet every 6 hours as needed for pain. LVN 1 removed one tablet from the package and administered the tablet to Resident 51. During a review of Resident 51's Physician Order Summary Report dated 4/3/21, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-04-29 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. Several food items in the kitchen refrigerator were unlabeled and undated. 2. Expired nutritional supplements were stored on the same shelf as nutritional products designated for current consumption. These failures had the potential to cause food contamination or food borne illness. Findings: 1. During an observation in the kitchen on 4/26/21 at 9:45 a.m., the refrigerator had the following unlabeled and undated items: two cups of apple sauce, an opened plastic bag of vegetables, and a tray containing twelve assorted drinks in glasses. During an interview with the Dietary Manager (DM) on 4/26/21 at 11:00 a.m., DM confirmed that the items were not dated and did not have a use by date. 2. During an observation in the hallway storage room on 4/28/21 at 11:03 a.m., a shelf contained the following expired items: one 8 Fluid ounce carton of Jevity (nutritional formula), expiration date of 2/19/2021; seven cans of Two-Cal HN (nutritional formula),…

    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 before2021-04-29 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of records the facility failed to ensure infection control policies and procedures were followed for three of six sampled residents (Resident 52, 306, and 307) when: 1. Licensed Vocational Nurse 1 (LVN 1) failed to perform necessary hand hygiene during wound care for Resident 52, and did not disinfect scissors used for the wound treatment before storing the scissors. 2. The facility failed to provide required Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury) readily available outside the residents room per policy and procedure, and that staff wore the necessary PPE for two of two residents (Resident 306 and 307). These failures had the potential to result in infection or spread of infection for Resident 52, 306, and 307 and increased exposure for all facility residents and staff. Findings: 1. During a review of Resident 52's admission Record, the Record indicated Resident 52 was…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-04-29 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of five sampled resident rooms had accurate wall clocks. This failure resulted in emotional distress from not knowing what time it was for two (Resident 306 and Resident 307) of four residents in the rooms with inaccurate wall clocks. Findings: During a review of Resident 306's admission Record, the Record showed Resident 306 was his own responsible party. During a review of Resident 306's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 4/28/21, the MDS indicated Resident 306 had a Brief Interview for Mental Status score of 13. (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) the MDS also indicated Resident 306 had adequate vision. During a review of Resident 307's Order Summary Report dated 4/27/21, the Report…

    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 before2021-04-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living 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 provide a homelike environment for two (Resident 39 and Resident 11) of 23 sampled residents when; 1. the facility did not address Resident 39's complaints of noise. 2. the facility did not replace Resident 11's broken television for over three weeks. For Resident 39 this failure resulted in decreased sleep and rest from excessive noise which caused mental and physical stress. For Resident 11, this failure resulted in less enjoyment of life from not being able to watch his favorite television shows on a screen large enough for him to see the shows. Findings: 1. A review of Resident 39's admission Record dated 4/27/21, indicated Resident 39 was admitted to the facility in 2015 with diagnoses which included muscle weakness, and cerebral infarction (stroke). The admission Record indicated Resident 39 had a family member, Responsible Party 1 (RP 1) for healthcare decisions. A review of Resident 5's admission Record dated 4/27/21, indicated Resident 5 was admitted to the facility in 2015 with diagnoses which…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-29 · 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 provide needed assistance with nail care for one of 22 sampled residents (Resident 1) when Resident 1's fingernails were untrimmed with sharp, chipped edges and black substance beneath the nail tips. This failure resulted in Resident 1 appearing poorly groomed with the potential to cause emotional distress and physical discomfort from injuries resulting from scratched skin from chipped nails. Findings: During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct care) dated 3/27/21, the MDS indicated Resident 1 had a diagnosis of cerebrovascular accident (CVA, impaired blood flow to the brain, commonly called a stroke) and was totally dependent on one person for assistance with personal hygiene. During a concurrent observation and interview on 4/27/21, at 9:50 a.m., with Certified Nursing Assistant 4 (CNA 4), Resident 1's right hand maintained a passive position of his fingers curled inward towards his palm (contracted). CNA 4 opened Resident 1's left hand and uncurled the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-29 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, for two residents (Resident 56 and Resident 39) the facility failed to inform residents and their responsible parties regarding the current facility visitation policy when: 1. The facility did not notify Resident 56 and her family that in-person visitation was allowed. 2. The facility did not notify Resident 39's Responsible Party 2 (RP 2, an individual responsible for health care decisions for a resident without capacity to make decisions) that in-person visitation was allowed. These failures resulted in feelings of depression and social isolation for Residents 56 and 39. Findings: 1. A review of Resident 56's admission Record on 4/26/21 at 11:00 a.m., indicated Resident 56 was admitted In February 2020 included diagnoses of anxiety, muscle weakness, and a broken right foot. During an observation and concurrent interview with Resident 56 on 4/26/21 at 11:46 a.m. Resident 56 complained the facility was not allowing her spouse to visit her in-person. Resident 56 stated she had seen other residents with visitors inside the facility…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-04-29 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure that one (Resident 11) of 22 sampled residents, received sevelamer (a medication that helps control blood phosphorus levels) according to physician orders. The failure to ensure Resident 11 received the correct dose of sevelamer had the potential to result in increased levels of phosphorus in the blood which can lead to decreased bone strength and broken bones. Findings: During a review of Resident 11's admission Record, dated 4/28/21, the admission Record indicated Resident 11 was admitted to the facility in 2014 with included diagnoses of end-stage renal disease (ESRD) requiring dialysis three times a week. (Dialysis, a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane. Dialysis is used for the treatment of end stage renal disease, the stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life.) During a review of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-29 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure 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 record review, the facility failed to ensure one of 22 sampled residents (Resident 16) received a meal at a nourishing and palatable temperature. The failure of dietary staff (Cook 2) to check the temperature of hot food items before plating and serving the meal to Resident 16 had the potential to result in scalds or burns from excessively hot food, or decreased intake and/or food borne illness from a meal cooked and/or served at an inadequate temperature. Findings: A review of Resident 16's admission Record showed an admission in June 2020 with included diagnoses of end stage renal disease and dependency on dialysis. (Dialysis is a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane. Dialysis is used for the treatment of end stage renal disease, the stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life.) During an observation on 4/27/21 at 11:38…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to BVHC, LLC — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.3+0.7 vs chain
Health inspection 4 of 53.0+1.0 vs chain
Staffing 4 of 53.4+0.6 vs chain
Quality measures 3 of 53.8-0.8 vs chain
The other 11 homes this chain runs (chain average 3.3★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
BOEHRER, BRYANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
CALABAZARON, REDENTORIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/14/2022
DHUGGA, GURPREETIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
MARTIN, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
TESSEMA, SINIDUIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/10/2021
THAPA, NISCHALIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/06/2024
WILCOX, SARAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2022

CMS files one row per role, so the 14 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$10.4M
Net patient revenuemost recent cost report
+6.7%
Operating marginrevenue minus expenses
$635K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 13%Other / private 10%

About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $635K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$414per resident / day
operating cost
$12,573per month
≈ monthly operating cost
$443per 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 056475. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-30, 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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