We Care Skilled Nursing Facility
21863 Vallejo Street, Hayward, CA 94541 · For profit - Corporation · 28 certified beds · (510) 750-1245 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- 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 number of inspection citations overall (27) — 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 0.0% | 10.2% | 15.4% | check this* — see note marked star below the table |
| Long-stay residents who lose too much weight | 0.0% | 4.0% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 7.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 1.6% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 0.0% | 9.8% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 14.8% | 13.7% | 18.9% | better |
| Long-stay residents with pressure ulcers | 9.0% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 21.4% | 10.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.0% | 12.0% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.0% | 93.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 20.2% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.0% | 11.2% | 12.0% | better |
* 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.
67.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 174 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 41 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.59 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 67.2%CMS range 61.0–74.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 7.6–13.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 70.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 75.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.9%CMS range 4.6–9.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.35 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 28 beds and averages 26.7 residents a day — about 95% occupied, or roughly 1 bed 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 3.90 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 is below 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 3.68 hrs/resident/day on weekends vs 3.98 on weekdays — 8% thinner on weekends. RN hours go from 0.34 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Ecited before2025-02-28 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan and meet the needs of three of three sampled residents (Resident 1, 9 and 14) when: 1. The facility did not develop a care plan to address Resident 1's peripherally inserted central catheter (PICC, a tube used to deliver medications and other treatments directly to the large central veins near the heart) care. 2. The facility did not develop a care plan to address Resident 9's weight loss of 2.4lbs (pounds) in one week due to very low food and fluid intake. 3. The facility did not develop a care plan to address Resident 14's hearing loss. These failures had the potential to result in Residents 1, 9, and 14 not receiving appropriate care, monitoring, and treatment. Findings: 1. During a record review of Resident 1's admission Record', printed on 2/27/25, the admission Record indicated Resident 1 was admitted to the facility in December 2024 with diagnosis of cellulitis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-28 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 medication rate was five (5) percent or less when three medication errors were observed out of 25 opportunities (medication error rate was calculated as followed: three divided by 25 then multiplied by 100, which was equal to 12 percent) when: 1.Resident 71 did not receive snack/food with Metformin (an oral medication to control blood glucose in the blood) tablet. 2.Licensed Nurse did not instruct Resident 12 to press inner canthus (inner corner of the eye where the upper and lower eyelids meet) after administering eye drops. 3.Licensed Nurse did not check Resident 5's Vital Signs (measurements of the body's most basic functions, including heart rate, pulse, temperature, respirations) before, during, and/or after nebulizer treatment. These failures placed Resident 71, Resident 12, and Resident 5 at risk for ineffective/compromised effects of above-mentioned medications. Findings: 1. A review of Resident 71's physician order dated 1/21/25, indicated to give one tablet of Metformin HCl) 850 milligrams…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-28 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to prepare food in accordance with professional standards of food service safety when: -Frozen meats inside the refrigerator were thawed on top of ready-to-drink fresh milk. -Multiple kitchen staff used the wrong test strip to check sanitizer concentration for the three-compartment sink and dishwasher. -Frozen chicken was thawed on the food preparation counter before cooking. -Two kitchen staff did not wear hair cover during food preparation. These failures had the potential to result in cross-contamination and food-borne illnesses. Findings: During an observation and concurrent interview on 2/24/25 at 10:22 a.m. with Dietary Manager (DM), inside the reach-in refrigerator, the following were observed: a) A pan overflowing with chicken and turkey, thawing on top of multiple gallons of fresh milk. DM stated there was not enough space in the refrigerator, so the staff had to somehow squeeze the meats in. b) DM tested the three-compartment sink sanitizer concentration by submerging two inches of the test strip in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-28 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing 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 ensure for one of four sampled residents (Resident 14), reviewed for communication deficit, received proper treatment to maintain hearing ability when hearing loss was not addressed by ht facility. This failure had the potential to result in the delayed access to hearing services. Findings: During a review of Resident 14's admission Record (AR), the AR indicated Resident was initially admitted to the facility in September 2024 with diagnoses that included muscle weakness, difficulty walking and end stage renal disease (ESRD, the final stage of long-term kidney disease when the kidneys are no longer sufficiently able to remove waste products and excess water to support the body's needs). During a review of Resident 14's Minimum Data Assessment (MDS, an assessment tool used to direct resident care) dated 9/18/24, the MDS indicated Resident 14 had adequate hearing. During a review of another MDS dated [DATE], the MDS indicated Resident 14 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide treatment and services to prevent urinary tract infection for one of one sampled resident (Resident 70), when staff did not follow-up on Resident 70's complaint of painful urination. This failure had the potential to result in delayed treatment. Findings: During a review of Resident 70's admission Record (AR), the AR indicated Resident 70 was admitted to the facility in December 2024 with diagnoses that included chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), muscle weakness, and diabetes mellitus (a chronic/long-term disease in which the body cannot regulate the amount of sugar in the blood). During review of Resident 70's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 12/27/24, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 monitor and assist in maintaining a sufficient food and fluid intake and for one of 20 sampled residents (Resident 9), when Resident 9 was not offered sufficient fluid intake and weight loss was not addressed to maintain proper hydration and health. This failure had the potential to result dehydration (dangerous loss of body fluid causes by illness or inadequate fluid intake) and further decline in Resident 9's health condition. Findings: During a review of Resident 9's admission Record', printed on 2/27/25, the admission Record indicated Resident 9 was admitted to the facility in February 2025 with multiple diagnoses including urinary tract infection (an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra) and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination. Symptoms usually begin gradually and worsen over time. As the disease progresses, people may 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.
- Potential for harm · D2025-02-28 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 1) with peripherally inserted central catheter (PICC, a long, thin, flexible tube that is placed into a small vein in the upper arm and moved forward until it is in a larger vein near the heart) received appropriate care and services consistent with professional standards of practice and in accordance with physician orders when Resident 1's PICC line dressing was not changed and monitored for complications. These failures had the potential for Resident 1 to develop complications such as infection and dislodgement (PICC line catheter displacement). Findings: During a record review of Resident 1's admission Record', printed on 2/27/25, the admission Record indicated Resident 1 was admitted to the facility in December 2024 with diagnosis of cellulitis (bacterial skin infection) of right and left lower limbs. During a record review of Resident 1's Order Summary, dated 2/27/25, the order summary indicated Resident 1 had an order to change the PICC line dressing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-28 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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
Based on interview and record review, for two of 15 sampled residents (Resident 3 and Resident 14), the facility failed to ensure; 1. An irregularity in Resident 14's medication regimen was identified by Consultant Pharmacist (CP) when fleet enema (laxative in the relief of occasional constipation, contains high levels of phosphates and sodium) was included in the bowel regimen despite Resident 14's constant refusal of phosphate binder. This failure had the potential to result in adverse events that included kidney injury. 2. Recommendation about Resident 3's medication regimen was not followed-through.This failure had the potential to result in increased risk of medication side effects. Findings: 1. During a review of Resident 14's admission Record (AR), the AR indicated Resident was initially admitted to the facility in September 2024 with diagnoses that included muscle weakness, difficulty walking and end stage renal disease (ESRD, the final stage of long-term kidney disease when the kidneys are no longer sufficiently able to remove waste products and excess water to support the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-28 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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, for one of five sampled residents (Resident 71) reviewed for unnecessary medications, the facility failed to ensure Resident 71 received apixaban (anticoagulant medication that has black box warning) with adequate monitoring for adverse effects. This failure had the potential to result in undetected adverse effects from the medication. Definition: Black Box Warning (BBW) is the strongest warning that the FDA (Food and Drug Administration) requires, and signifies that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects. Findings: During a review of Resident 71's admission Record (AR), the AR indicated, Resident 71 was admitted to the facility in January 2025 with diagnoses that included heart failure and atrial fibrillation (common heart rhythm disorder where the upper chambers of the heart [atria] beat irregularly and rapidly) and difficulty walking. During a review of Resident 71's Order Summary Report dated 2/27/25, the Order Summary Report indicated an order for apixaban oral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-28 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow the food preference and therapeutic diet as ordered by the physician for one out of 20 sampled residents (Resident 10). These failures had the potential to result in Resident 10 feeling disrespected and placed Resident 10 at risk for choking. Findings: During a review of Resident 10's admission Record, printed 2/27/25, the record indicated Resident 10 was admitted to the facility in November 2023 with a diagnoses of low back pain and chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis.) During a record review of Resident 10's undated Breakfast Meal Ticket, the meal ticket indicated Resident 10's diet was controlled carbohydrates (a diet that is designed to manage blood sugar levels) diet with mechanical soft texture (consist of soft, easily chewed and swallowed foods). The meal ticket also indicated Dislikes: Cereal, ravioli, cranberry juice, sausage . and Beverages: 2 milks.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · Dcited before2025-02-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices when following was noted: 1. Seven (7) out of seven expired Intravenous Administration sets (IV kit, a medical device used to deliver nutrients and medications in a fluid form directly into patient's bloodstream) were kept in the medication storage room. 2. One (1) out of one expired Peripherally Inserted Central Catheter (PICC, a long, flexible thin tube, also known as catheter, put into a vein in upper arm for extended use) stabilizing device (a device to stabilize the wings of PICC line) were kept with ready to use medication administration supplies. This failure placed facility residents at risk for receiving medications via expired and with compromised sterility IV/ PICC line devices. Findings: During an observation and concurrent interview on [DATE] at 10:00 a.m. with Licensed Vocational Nurse (LVN 1), in facility's medication storage room, seven IV Kits with expiration date of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-31 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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, record review, and facility policy review, the facility failed to ensure one (Resident 1) of three sampled residents was free from unnecessary drugs when facility's interdisciplinary team (IDT) did not re-evaluate use of Seroquel (an antipsychotic medication) at the time of admission and/ or within two weeks for its appropriateness and indication for use to consider whether or not the medication could be reduced, tapered, or discontinued. Interdisciplinary team is a group of healthcare professionals who work together to treat a patient condition. This failure had the potential for Resident 1 to receive unnecessary medications and placed her at risk to suffer adverse effects from the medication. Findings: During a review of Resident 1's admission Record (AR), dated 12/23/24, the AR indicated, Resident 1 was admitted from acute care hospital on 8/22/24. During a review of Resident 1's Admission-Minimum Data Set (MDS- Resident Assessment and care guide tool) dated 8/26/24, the MDS indicated Resident 1 had no potential indicators of psychosis e.g., hallucinations…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-10-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store food safely when food in the refrigerator, chest freezer, reach-in freezer, and dry storage were unlabeled and undated. This failure has the potential of placing 21 out of 21 residents at risk for foodborne illnesses. Findings: During a concurrent observation and interview on 10/16/23, at 9:38 a.m., with Kitchen Supervisor (KS), during initial kitchen tour, in the chest freezer, 5 bags of broccoli had no date, two Ziploc bags of corn on the cob did not have label or date, and one package of turkey sausage with a date of 6/17/23. In the reach-in freezer, two bags totaling 24 veggie patties were without date and appeared with ice crystals inside the bag, two clear bags totaling 12 cheese pizzas were without label or date, 1 bag of frozen turkey was dated 6/23/23, 5 brown bags of French fries were unlabeled and undated, one package of frozen chopped meat was unlabeled and undated, and three bags of frozen raw chicken was unlabeled and undated. Inside the dry storage area, four 1-gallon containers of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-19 · tag F0759 — failed to keep medication error rate low — patternEnsure 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, interview and record review, the facility failed to administer medications below a five percent (5%) error rate when: 1. Licensed Vocational Nurse (LVN )1 gave Insulin Aspart (a drug used to treat diabetes; a condition that develops when a person's blood sugar is too high) 2 units, late to one (Resident 10) of 10 sampled residents. 2. LVN 1 gave Metformin 850 mg (a drug used to treat diabetes; a condition that develops when a person's blood sugar is too high), after lunch was finished and not with lunch, to one (Resident 12) of 10 sampled residents. These errors resulted in Resident 10 and 12, not receiving medication as prescribed by their physicians. Findings: During a review of Resident 10's admission Record (AR), dated 10/19/23, the AR indicated Resident 10 was originally admitted to the facility on [DATE], and had a diagnosis of Diabetes Mellitus (a condition that develops when a person's blood sugar is too high). During a review of Resident 12's admission Record (AR), dated 10/19/23,…
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.
- Potential for harm · D2023-10-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 serve puree meals on plates (they were served in cups) for two residents (Resident 3 and Resident 120) out of 12 sampled residents. This failure had the potential to cause residents, who are on altered textures to lose their rights to be treated with dignity. Findings: During a review of Resident 3's admission Record, the admission Record indicated, admission of date of 3/25/23 with diagnoses including Other sequelae of cerebral infarction (residual effects after a stroke). During a review of Resident 120's admission Record, the admission Record indicated, admission date of 10/9/23 with diagnoses including Encounter for Palliative care (comfort care for terminally ill residents) and dysphagia (trouble swallowing). During a review of Resident 3's Physician Orders, dated 10/2023, the Physician Orders indicated, Resident 3 is on regular diet, puree texture, and thin liquids. During a review of Resident 120's Physician Orders, dated 10/2023,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow physician orders when administering oxygen to one resident (Resident 170) out of 12 sampled residents. This failure has the potential to cause Resident 170 to be given too much oxygen, which could result in hospitalization. Findings: During a review of Resident 170's admission Record, the admission Record indicated a readmission date of 7/26/23 with diagnosis including Chronic Obstructive Pulmonary Disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe). During an observation on 10/16/23 at 9:12 a.m., in Resident 170's room, Resident 170 was asleep with oxygen via nasal cannula (a device used to deliver supplemental oxygen) at 2.5L/min. During a follow up observation and interview on 10/18/23 at 10:54 a.m., with Resident 170, inside Resident 170's room, Resident 170 was observed with nasal cannula and supplemental oxygen was delivered at 2.5L/min. Resident 170 stated, he uses oxygen mostly at night. During a concurrent record review and interview on 10/18/23 at 10:55 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.
- Potential for harm · Dcited before2023-10-19 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to ensure dialysis (a treatment to remove extra fluid and waste products from the blood when the kidneys cannot) communication records were completed for one (Resident 6) of one sampled resident. This failure had the potential to miss signs of illness such as fever or bleeding, which could lead to hospitalization. Findings: A review of Resident 6s admission record, the admission record indicated, admission date of 7/23/23 with diagnoses including end stage renal disease (the last stage of long-term kidney disease where the kidneys no longer work) and dependence on renal dialysis. During a review of Resident 6's Order Summary Report, the Order Summary Report indicated, Resident 6 had dialysis three times a week on Tuesdays, Thursdays, and Saturdays. During a record review of Resident 6's Hemodialysis Communication records dated 9/12/23 through 10/17/23, the Hemodialysis Communication records for hemodialysis treatment days on 9/12/23, 10/7/23 and 19/17/23 were not completed. During a concurrent interview and record review, 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.
- Potential for harm · D2023-10-19 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 gave Insulin Aspart (a drug used to treat diabetes; a condition that develops when a person's blood sugar is too high) 2 units, late to one (Resident 10) of 10 sampled residents. This failure resulted in Resident 10 not receiving medication as prescribed by the physician and placed Resident 10's health at risk due to risk of a negative effect on Resident 10s blood sugar. Findings: During a review of Resident 10's admission Record (AR), dated 10/19/23, the AR indicated Resident 10 was admitted to the facility on [DATE], and had a diagnosis of Diabetes Mellitus (a condition that develops when a person's blood sugar is too high). During an observation on 10/17/23 at 2:12 p.m., Licensed Vocational Nurse (LVN) 1 was observed giving the medication, Insulin Aspart 2 units, to Resident 10. During a concurrent interview and record review on 10/17/23 at 2:15 p.m., with LVN 1, Resident 10's Medication Administration Record (MAR) was reviewed. The MAR…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff followed the infection control program designed to prevent the spread of infection for one of 10 sampled residents (Resident 10) when Licensed Vocational Nurse (LVN) 1 failed to perform hand hygiene after removing gloves, LVN 1 had put on to give eye drops. This failure had the potential to cause infection or spread infection. Findings: During a review of Resident 10's admission Record (AR), dated 10/19/23, the AR indicated Resident 10 was originally admitted to the facility on [DATE]. During an observation on 10/17/23 at 1:18 p.m., in Resident 10's room, LVN 1 put on gloves. LVN 1 then put one drop of Dorzolamide-Timolol (a medication used to treat glaucoma, a condition in which the pressure inside the eye is abnormally high) in Resident 10's right eye. Then LVN 1 took off the gloves and left Resident 10's room. LVN 1 did not perform hand hygiene after taking off the gloves. During an interview on 10/17/23 at 1:21 p.m., LVN 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.
- Potential for harm · E2022-04-22 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to follow the lunch menu set for 4/18/22 when cut up watermelon was served to residents instead of apple crisp. This deficient practice resulted in Resident 20 feeling disappointed. Findings: During a concurrent observation and interview on 4/18/22, at 10:45 a.m. with Dietary Manager (DM), there was cut up watermelon in the refrigerator. DM stated, it was left over from the weekend and it is still OK to use today. She further stated, it will be served for lunch. During an observation and interview on 4/18/22, at 12:38 p.m., Resident 20 was eating her lunch in her room and was reading the menu. Resident 20 noticed on the menu that apple crisp was the desert for 4/18/22's lunch. Resident 20 stated, there was no apple crisp on her lunch tray, but instead it was cut up watermelon. Resident 20 stated, she was disappointed there was no apple crisp. Resident 20 further stated, staff did not notify her of any changes in the menu this morning. During an interview on 4/21/22, at 10:42 a.m. with Registered Dietician (RD),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-04-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store food in a sanitary manner when ground pork was thawing on top of strawberry gelatin inside the refrigerator. This deficient practice had the potential to cause food borne illness and affect all residents. The facility census was 17. Findings: During a concurrent observation and interview on 4/18/22, at 10:45 a.m. in the kitchen, ground pork was thawing in a shallow pan on top of strawberry gelatin in the refrigerator. DM stated, thawing meat should be at the very bottom of the refrigerator and not on top of anything to prevent food borne illnesses. During an interview on 4/21/22, at 10:42 a.m. with Registered Dietician (RD), RD stated, thawing of any meat should be done at the very bottom of a refrigerator and never on top of any food to prevent food borne illnesses. A review of the facility's policy titled, Policy: Thawing of Meats, dated 2018, the policy indicated, a. Use a drip pan under food being thawed so drippings do not contaminate other food. B. Thaw meat on the bottom shelf below prepared,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-04-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet the needs for two (Resident 8 and Resident 10) of 16 sampled residents when the facility did not develop and implement a care plan for Resident 8's dialysis (treatment of kidney failure that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood) care and for Resident 10's hospice care. This deficient practice may result in Resident 8 and Resident 10's physical, psychosocial and functional needs to go unmet. Findings: 1. A review of Resident 8's Facesheet, dated 4/20/22, the face sheet indicated Resident 8 was admitted on [DATE] with a diagnosis of an infected dialysis catheter (tube inserted into the vein). A review of Resident 8's Minimum Data Set (MDS- an assessment tool) dated 2/10/22, the MDS indicated Resident 8 is on dialysis treatment. During an interview on 4/20/22 at 9:53 a.m. with Dialysis Nurse, Dialysis Nurse stated, Resident 8 had been receiving dialysis at Dialysis Nurse's clinic since February…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-04-22 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview record review, the facility failed to provide care for one (Resident 8) requring dialysis when staff did not do a complete physical assessment before and after Resident 8's dialysis treatment. This deficient practice resulted in an incomplete assessment of Resident 8's dialysis access site before treatment. Findings: A review of Resident 8's admission Record, the admission Record indicated, Resident 8 was admitted on [DATE], with a diagnosis of infected dialysis catheter. A review of Resident 8's Minimum Data Set (MDS- an assessment tool) dated 2/10/22, the MDS indicated, Resident 8 is on dialysis. During an interview on 4/20/22, at 9:53 a.m. with Dialysis Nurse, Dialysis Nurse stated, Resident 8 had been receiving dialysis at Dialysis Nurse's clinic since February 2022. Dialysis Nurse stated, the dialysis access site used for Resident 8 had always been the left upper chest catheter. Dialysis Nurse further stated, Resident 8's left upper arm graft had not been used since admission at the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-04-22 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 store medications according to manufacturer recommendations and label medications appropriately when one bottle of Dorzolamide (prescription eye drops given for glaucoma, a condition where there is increased pressure in the eye) was stored in the refrigerator at 39 degrees Fahrenheit. This failure had the potential to cause resident to be administered ineffective medication resulting in worsening of their condition leading to damage of the eye. Findings: During a concurrent observation and interview on 04/20/2022, at 11:45 a.m., with Licensed Vocational Nurse 1 (LVN 1) inside the medication storage room, a bottle of dorzolamide was found stored inside the refrigerator. LVN 1 confirmed refrigerator temperature was 39 degrees Fahrenheit. LVN 1 stated, medications that are stored improperly could potentially be ineffective. During an interview with Director of Nursing (DON) on 04/20/2022 at 2:12 p.m., DON stated, medications should be stored according to manufacturer's recommendation. During a review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-04-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure one nursing staff performed hand hygiene (handwashing or use of an alcohol-based hand sanitizer) during medication administration when Licensed Vocational Nurse 1 (LVN 1) failed to perform hand hygiene after removing gloves after giving medications to Resident 5 and Resident 8. These failures had the potential to cause or spread infection which could result in hospitalization for Resident 5 and Resident 8. Findings: During an observation on 04/20/2022, at 9:00 a.m., outside of Resident 5's room, Licensed Vocational Nurse 1 (LVN 1), was observed doffing (taking off) gloves and exiting the resident's room after administering medications without performing hand hygiene. During a subsequent observation at 10:45 a.m., outside of Resident 8's room, LVN 1 also did not perform hand hygiene after doffing gloves after administering medication to Resident 8. During an interview on 04/20/2022, with Licensed Vocational Nurse 1 (LVN 1) , at 11:08 a.m., LVN 1 stated, hand hygiene should be done before entering…
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.
- No harm found · B2023-10-19 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 residents who occupied 3 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 multiple room observations on 10/16/23 through 10/19/23, there were three residents in Rooms 3, 5 and 10, which are 4 bed rooms. 1. room [ROOM NUMBER] measured 20.4 feet by 14 feet which equaled 71.4 square feet per resident. 2. room [ROOM NUMBER] measured 20.4 feet by 14 feet which equaled 71.4 square feet per resident. 3. room [ROOM NUMBER] measured 20.4 feet by 14 feet which equaled 71.4 square feet per resident. During random observations of care and services from 10/16/23 to 10/19/23, there was sufficient space for the provision of care for the residents in all rooms. There were no heavy equipment in the rooms that might interfere 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.
- No harm found · B2022-04-22 · tag F0912 — patternProvide 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 9 of 17 residents in the following multiple resident bedrooms 3, 10, 15 with at least 80 square feet per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for residents to have personal belongings at the bedside. Findings: During an observation on 4/20/22, accompanied by the Maintenance Supervisor (MS), MS measured the following multiple resident rooms in feet (ft) and inches (in): 1) a. room [ROOM NUMBER]: b. 20.4' x 14' c. Total Square Feet: 286.6 d. #Residents 2: 3 e. Square Feet/resident 71.4' 2) a. room [ROOM NUMBER]: b.20.4' x 14' c. Total Square Feet: 286.6 d. # Residents: 3 e. Square Feet/resident 71.4' 3) a. room [ROOM NUMBER] b. 20.4' 14' c. Total Square Feet: 286.6 d. # Residents: 2 e. Square Feet/resident 71.4' During an interview on 4/21/22 at 12:57p.m. with Administrator (Admin), Admin stated, there 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| JAIN, ASHIT | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 08/22/2020 |
| WE CARE SKILLED NURSING FACILITY | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/28/2025 |
| PONDER, ALDWIN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2022 |
CMS files one row per role, so the 11 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555914. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-28, 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.