Community Care Center
8665 La Mesa Blvd., La Mesa, CA 91942 · For profit - Limited Liability company · 119 certified beds · (619) 465-0702 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- it has a citation for mishandling residents’ money or property (F0567)
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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.
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 | 5.8% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.9% | 4.0% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 1.3% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.3% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.9% | 7.3% | 6.5% | typical |
| 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 | 0.6% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 11.0% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.5% | 13.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.3% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 6.1% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.2% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.7% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 96.4% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.4% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.4% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.90 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.93 | 1.57 | 1.80 | better |
‡ 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.
54.4% 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 166 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 40.7% 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 86 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 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 31% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 54.4%CMS range 46.2–62.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.1%CMS range 9.2–16.8 | 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 | 40.7% | 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 | 45.4% | 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 | 30.2% | 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 | 100.0% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.2% | 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 | 0.5% | 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 | 5.9%CMS range 4.0–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.16 | 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 119 beds and averages 104.2 residents a day — about 88% occupied, or roughly 15 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.78 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 4.22 hrs/resident/day on weekends vs 4.77 on weekdays — 12% thinner on weekends. RN hours go from 0.85 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% 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
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.
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 · D2026-06-02 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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 safe discharge teaching and caregiver training, including return demonstration and evaluation of the caregiver's ability to assist with activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), for one of three sampled residents (Resident 1) reviewed for discharge planning. As a result, the facility discharged Resident 1 to a hotel with a son identified as the primary caregiver despite concerns related to unstable housing, reported intoxication, lack of caregiver training, and failure to evaluate caregiver competency to safely meet Resident 1's 24-hour care needs. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing),cerebrovascular (CVA-…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-30 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 safe and effective pharmaceutical services when:Random controlled medication (medications with a high abuse potential) use audit for three of four sampled residents (Residents 73, 4, and 50) indicated medications were signed out of the controlled drug record (CDR, count sheet used to track controlled medications), but were not documented on the Medication Administration Record (MAR, section of the medical record where all medications given to the resident are recorded to ensure patient safety) to indicate they were administered to the residents. In addition, for Resident 50, an administration was documented on the MAR, but not signed out on the CDR. These failures had the potential for diversion (unlawful distribution or use), inadequate narcotic accountability, and the potential to not meet the needs of the residents in the facility.Medications were not administered as prescribed for one of four residents sampled for controlled medication audits (Resident 50) and for one of five residents sampled for unnecessary…
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 before2026-04-30 · 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 ensure one of one sampled resident (17) reviewed for dignity had sufficient personal clothing of choice and footwear.This failure resulted in Resident 17 remaining in a hospital gown instead of personal clothing and without available footwear, with the potential to diminish the resident's sense of self-worth.Resident 17 was admitted to the facility on [DATE] with a diagnosis of cachexia (severe weight loss and muscle wasting caused by serious illness) per the facility admission record.During an observation and interview on 4/29/26 at 9:50 A.M., Resident 17 sat in bed wearing a hospital gown. Resident 17 stated she was in her hospital gown because she did not have enough personal clothing and wanted to purchase clothing of her choice. Resident 17 stated she had requested access to her personal funds to buy clothing, but the facility had not provided the money after she made the request. Resident 17's closet contained one jacket, one dress,…
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 · D2026-04-30 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
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 one sampled resident (17) had access to personal funds when the resident requested money to purchase clothing of choice. As a result, Resident 17 was unable to purchase desired clothing and continued to wear a hospital gown.Resident 17 was admitted to the facility on [DATE] with a diagnosis of cachexia (severe weight loss and muscle wasting caused by serious illness) per the facility admission record.During an observation and interview on 4/29/26 at 9:50 A.M., Resident 17 sat in bed wearing a hospital gown. Resident 17 stated she wore the hospital gown because she did not have enough personal clothing. Resident 17 stated she wanted to buy clothing of her choosing and had requested access to her money, but the facility had not provided access to her money. Resident 17 stated she was supposed to receive around $1000 from social security on a monthly basis.During a concurrent observation and interview with Resident 17 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.
- Potential for harm · D2026-04-30 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility did not ensure professional standards were followed when a resident's change in condition was not followed up on for one of three residents (Resident 10) observed for changes in condition. This failure had the potential for harm due to no follow up of a noted change.Resident 10 was originally admitted to the facility on [DATE], with diagnosis that included: acute (sudden, new) and chronic (over six months) respiratory failure (the lungs cannot deliver enough oxygen to the body and remove carbon dioxide, causing organ damage), muscle spasm; contracture of right and left knees (Contractures are the permanent, abnormal tightening of skin, muscles, tendons, or ligaments, causing joint stiffness and limited movement range {ROM}, according to Resident 10's admission record.On 4/29/26 at 9 A.M., a simultaneous interview and record review was held with the Director of Rehab. (DRH). A Restorative Nurse's Aide (RNA- a health care worker with training in physical therapy) weekly summary dated 4/11/26 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.
- Potential for harm · D2026-04-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to record and document fluid intake for one resident (118) on intravenous (IV - a medical method of delivering fluids, medication, or blood directly into a vein using a small tube and needle) therapy.This failure had the potential for fluid mismanagement that can lead to fluid overload (when the body retains too much water, causing it to build up in blood vessels and tissues) or dehydration (when the body loses more fluids than it takes in, causing it to lack enough water to function normally) to Resident 118.Per the facility's admission sheet, Resident 118 was admitted to the facility on [DATE] with diagnoses that included dysphagia (trouble swallowing). On 4/27/26 at 8:10 A.M., an observation was conducted of Resident 118 in his room. Resident 118 had a peripheral intravenous (PIV - a small, flexible plastic tube inserted into a minor vein to deliver fluids, medication, or blood directly into the bloodstream) line on the back of his right…
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 · D2026-04-30 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not monitor for and treat signs of pain for one of one clients (23) reviewed. This failure caused Client 23 to experience avoidable discomfort.Findings: Resident 23 was admitted to the facility on [DATE], with diagnosis that included: anoxic brain damage (a condition where the brain was cut off from oxygen, leading to brain cell death) and acute (sudden) and chronic (long term, over six months) respiratory failure (a condition where the lungs cannot supply enough oxygen to organs). Resident 23 had a tracheostomy (a surgically created hole in the neck to allow air into the windpipe) and was totally fed via gastrostomy (g-tube: a surgically created hole in the stomach with a tube inserted to accept formula nutrition). Resident 23 was unable to speak, and dependent on staff for all Activities of Daily Living (ADL's - dressing, oral care, hygiene, etc.), according to her admission Record and her Plan of Care. On 4/28/26 at 11:05 A.M., Resident 23'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.
- Potential for harm · D2026-04-30 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 11.54% when three medication errors occurred out of 26 opportunities during the medication administration for three of five randomly observed residents (Residents 53, 85, and 106). These failures had the potential for the residents not to get the full therapeutic benefit of their medications or to experience negative health outcomes, such as harm from exposure to medication errors.Findings:During a medication administration observation on 4/27/26 at 7:51 A.M., Licensed Nurse (LN) 30 was observed preparing and administering six medications for Resident 53. The medications included the following tablet: calcium carbonate (a supplement for low calcium) 500 milligram (mg, unit of measurement) chewable tablet.A review of Resident 53's medical record indicated she had an active order for calcium carbonate oral tablet - give 500 mg by mouth four times a day for supplement, dated 10/28/23.A drug review of calcium…
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 · D2026-04-30 · 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
Based on interview and record review, the facility failed to ensure residents were free of significant medication errors when one of five residents sampled for unnecessary medications (Resident 93) and two of four sampled residents for controlled medication use audits (Residents 73 and 4) received pain medications that were not in accordance with the prescribers' orders. This failure had the potential for diversion (unlawful distribution or use), as well as the potential for Residents 93, 73 and 4 to experience physical dependence (unpleasant symptoms if a medication is suddenly stopped) and adverse effects, such as sedation (sleepiness), dizziness and respiratory depression (slowed or shallow breathing).Findings:A review of Resident 93's medical record indicated an order for oxycodone-acetaminophen (a controlled medication used to manage pain) 7.5/325 mg (milligram, unit of measure) tablet - give one tablet by mouth every 4 hours as needed for severe pain (7-10 level pain, 0 being no pain, 10 being the worst pain imaginable), started 3/11/26.During a concurrent interview and record…
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 · D2026-04-30 · 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 ensure safe and effective prescription labeling when a portion of both a prescription label and the handwritten date opened were missing on a medication in one of four inspected Medication Carts for Resident 38. This failure had the potential to negatively alter the drug's stability and effectiveness and for Resident 38 to experience adverse health outcomes.Findings:During a concurrent observation and interview on 4/27/26 at 9:11 A.M. with Licensed Nurse (LN) 33, an inspection of the Station 1 Medication Cart 2 was conducted. Two plastic bags containing foil pouches of ipratropium-albuterol (a medication used to treat respiratory conditions) nebulizer (a device that changes a liquid medication into an inhalable mist) vials for Resident 38 were found. The prescription label on one of the plastic bags was observed to be missing part of the label which provided the directions for using the medication. LN 33 acknowledged that a portion of the prescription label was missing on that bag. The other bag contained an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · Dcited before2026-04-30 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 maintain sanitary food storage and food service practices when individual size milk cartons were stored in boxes saturated in standing water inside a refrigerator, and when resident meals were cooked and plated for service without verifying cooking and holding temperatures. This failure had the potential to expose residents to foodborne illness from consuming contaminated beverage cartons and serving food to residents without a verified safe cooking temperature.During an observation and interview on 4/27/26 at 9:30 A.M., the kitchen's dairy refrigerator was inspected with the dietary supervisor (DS). The three-door reach-in refrigerator had approximately one inch of standing water that extended across the entire bottom shelf of the refrigerator. Six large cardboard boxes containing 4-ounce cartons of milk had been spread across three large metal pans that were faced down in the water at the bottom of the refrigerator. The bottom of two large cardboard boxes were saturated with water. Upon inspection 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 before2025-07-11 · 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 interview and record review, the facility's nursing staff failed to maintain the dignity of one sampled resident (Resident 1) when Resident 1 arrived to the dialysis center (a facility where patients undergo a procedure to remove toxins from the blood) wearing only briefs and a blanket. This failure had the potential to cause the resident embarrassment and had the potential to lower self-esteem.Findings:During a record review on 6/13/25, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (kidney failure), and dependence on renal dialysis.During a record review on 6/13/25, the Physician's Orders indicated Resident 1 was taken to an outside dialysis center every Monday, Wednesday, and Friday.During a record review on 6/13/25, the Minimum Data Set (MDS- an assessment tool) indicated Resident 1 had a BIMS (Brief Interview for Mental Status- a tool to measure cognition, or mental processes such as memory, perception, decision…
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 · E2025-02-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide 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 prevent and treat three of five residents (Residents 99, 11 and 12) who were identified as being at risk of pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence) when: 1a. Resident 99 was not turned and repositioned every two hours; 1b. Resident 99 had missing entries on his daily wound treatment log; and 2. Resident 11 had missing entries on her daily wound treatment log; and 3. Resident 12 had missing entries on her daily wound treatment log. These failures had the potential for additional or worsening skin injuries to occur. 1a. Resident 99 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer (damage to the skin and tissue caused by prolonged pressure on the skin) of the left heel, Stage 4, (a full-thickness tissue loss that exposes bone, muscle, and/or tendon), per the facility's admission Record. An observation was conducted of Resident…
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 before2025-02-13 · 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 ensure food safety and sanitation practices were met in the kitchen according to standards of practice, when two green cutting boards with deep cuts and food stains were stored in the clean area. In addition, one red cutting board and one brown cutting board with deep cuts were also stored in the clean area, when reviewed for food sanitation. This failure exposed residents to contaminated food surfaces and unsanitary practices, which had the potential to place them at risk of developing foodborne illness. Findings: On 2/12/25 at 11:13 A.M. an observation and interview was conducted with Dietary Worker 1 (DW 1). A green chopping board was observed on the kitchen counter, next to the 3-compartment sink. The cutting board had multiple knife cuts and scratches on both sides. There were dark brown colored stains visible in the scratches and on the chopping board surface. DW 1 stated the cutting board had just been washed and was in the drying area. A second green chopping board was observed hanging above 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 · D2025-02-13 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer the correct amount of oxygen, according to the physician's order for one of two residents (Resident 99), reviewed for oxygen therapy. This failure had the potential for too much carbon dioxide to accumulate in the blood, affecting the body's blood pH, respiratory drive, and the blood cells affinity for oxygen. Findings: Resident 99 was admitted to the facility on [DATE], with diagnoses which included chronic (persisting for a long time) respiratory failure with hypoxia (insufficient amount of oxygen in the body's tissues) and encounter for attention to tracheotomy (a surgical procedure that creates an opening in the front of the neck [trachea] in order to provide an airway), per the facility's admission Record. An observation was conducted of Resident 99 on 2/10/25 at 9:01 A.M. as he laid in bed. Resident 99 had a stoma (a surgical opening in the neck that allows a person to breathe without a tube inserted). The stoma 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.
- Potential for harm · D2025-02-13 · tag F0802 — failed to prepare enough nourishing food — isolatedProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure the kitchen staff competently performed and carried out the functions of the Food and Nutrition Service department when [NAME] 1 could not properly demonstrate how to calibrate a food thermometer, when reviewed for competency. This failure had the potential for food contamination, resulting in food borne illnesses for all residents who consumed food from the kitchen. Findings: During a joint observation and interview on 2/12/25 at 10:52 A.M. with [NAME] 1, [NAME] 1 was asked to demonstrate how to properly calibrate an analog thermometer (device that measures temperature by using mercury or alcohol). [NAME] 1 began to twist the thermometer's probe and stated, .I have to move the line [dial] to 0 [degrees Fahrenheit] then I put it in the water .you don't need to put it in the water if its already on 32 degrees . On 2/13/25 an interview was conducted with the Dietary Supervisor (DS). The DS stated it was his expectation for all kitchen staff to know how to calibrate thermometers properly, whether it is a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-13 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, ad record review, the facility failed to accurately document antibiotic (drugs which treat infections) administration in one of two residents (Resident 88) clinical record, when reviewed for Antibiotic Therapy. This failure had the potential for Resident 88's clinical record to be incomplete and inaccurate. Findings: Resident 88 was admitted to the facility on [DATE], with diagnoses which included osteomyelitis (a bone infection) of the thoracic (upper spine) and lumbar (lower spine), region, per the facility's admission Record. An observation was conducted of Resident 88 in his room on 2/10/25 at 10:17 A.M. Resident 88 was asleep in bed and an intravenous (IV-a medication bag which delivers fluid and medication to a vein) bag was infusing via an IV pump (a machine which delivers a certain amount of medication per minute). The exterior door to the resident's room was labeled as Contact precautions (infection control measures used to prevent the transmission of infectious agents…
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 before2025-02-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents was free from unnecessary drugs when 1) Resident 1 did not have an appropriate diagnosis for a psychotropic medication. 2) An anti-anxiety medication was administered to Resident 1 past the 14 day limit without reassessment from the physician. These failures had the potential to harm Resident 1 when an unnecessary psychotropic medications was administered. Findings: 1. According to the Face Sheet, Resident 1 was admitted on [DATE] with diagnoses which included respiratory failure and cerebral palsy (a disorder that affects movement, balance, and posture) . According to the Minimum Data Set (MDS-an assessment tool) dated 8/11/21, Resident 1 was never or rarely understood, and was severely cognitively impaired. The MDS also indicated, Resident 1 had No speech- absence of spoken words, was Rarely/never understood and Rarely/never understands others. During a record review on 12/26/24, Resident 1'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.
- Potential for harm · D2025-02-04 · 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 implement infection control measure when three of nine Subacute resident rooms were reviewed. 1) A housekeeper was observed removing Personal Based onProtective Equipment (PPE-gown, gloves, masks) in the hallway outside of an Enhanced Barrier Precaution (EBP--a type of infection control strategy where PPE is worn when providing high-contact care to residents) resident room. 2) A visitor was in an Enhanced Barrier Precaution room providing care without wearing PPE. These failures had the potential to spread infection among staff and visitors. Findings: 1. During a tour of the facility on 1/8/25 at 11:15 A.M. Housekeeper (HK) 1 was observed exiting an Enhanced Barrier Precaution room [resident room [ROOM NUMBER]] wearing PPE. HK 1 was observed removing the PPE in the hallway and discarding it in the housekeeping cart outside the room. On 1/8/25 Resident 1's record was reviewed. According to the Face Sheet, Resident 1 was admitted on [DATE]…
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 before2024-12-31 · 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 follow the physician plan of care related to weekly weights and notification of the physician when the vital signs (blood pressure, heart rate, respiratory rate, and temperature) were outside of the parameters set (a measurable limit), for one of three residents (Resident 1), reviewed for care plans. This failure had the potential for the physician to be uninformed of changes, which could have negative consequences on Resident 1's overall health. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included down syndrome (a genetic condition which affects the brain and normal development) and severe constipation (hard, dry stool, that is difficult to pass), per the facility's admission Record. A review of Resident 1's clinical record was reviewed on 12/18/24: According to the admission Minimum Data Set (MDS-a clinical assessment tool), dated 11/11/24, the cognitive assessment score was 00, indicating cognition was severely…
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 before2024-08-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a care plan for one of three residents (Resident 1) reviewed for foley catheters. This failure placed Resident 1 at risk for complications related to the foley catheter, including infection. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included surgical amputation of the right leg, and stage 4 pressure ulcer of the right buttock, left buttock, and right heel, according to the admission Record. The admission Nursing Assessment, dated 4/13/24, indicated Resident 1 had an indwelling foley catheter (a tube inserted into the bladder which collects urine) present upon admission. On 8/5/24 at 2:21 P.M., a joint interview and record review was conducted with the infection preventionist nurse (IPN). The IPN stated a physician's order for a foley catheter was entered into Resident 1's chart on 4/23/24, but it should have been entered upon admission on [DATE]. The IPN further stated there was no care…
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 · D2024-02-29 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurate for 1 (Resident #93) of 5 residents reviewed for unnecessary medications. Specifically, the facility failed to ensure Resident #93's MDS reflected the resident's diagnosis of schizophrenia. Findings included: A review of facility policy titled, Resident Assessment, revised in March 2022, revealed, All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. A review of an admission Record revealed the facility admitted Resident #93 on 10/26/2023. According to the admission Record, Resident #93 had a medical history that included diagnoses of schizophrenia, depression, and anxiety disorder. A review of Resident #93's comprehensive care plan revealed a Focus area, initiated on 10/26/2023, that indicated the resident had an impaired mood state/depression as evidenced by behavioral manifestations related to diagnoses that included anxiety disorder,…
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 · D2024-02-29 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, the facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASRR) Level I Screening for 1 (Resident #93) of 3 sampled residents reviewed for PASRR requirements. Specifically, the facility failed to ensure Resident #93's PASRR Level I Screening reflected the resident had diagnosed mental disorders, including depression, anxiety disorder, and schizophrenia. Findings included: A review of facility policy titled, admission Criteria, revised in March 2019, revealed, All new admissions and readmission are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review process. A review of an admission Record revealed the facility admitted Resident #93 on 10/26/2023. According to the admission Record, Resident #93 had a medical history that included diagnoses of schizophrenia, depression, and anxiety disorder. A review of Resident #93's comprehensive care plan revealed a Focus area, initiated 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 · D2024-02-29 · 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 observations, interviews, record review, and facility policy review, the facility failed to document and monitor the implementation of physician prescribed fluid restrictions for 1 (Resident #162) of 1 sampled resident reviewed for dialysis and with a prescribed fluid restriction. Specifically, Resident #162, who received renal dialysis, had a physician's order for a 1500 milliliter (mL) fluid restriction each day, and the facility failed to document and monitor the amount of fluids Resident #162 consumed. Findings included: A review of a facility policy titled, Encouraging and Restricting Fluids, revised in October 2010, revealed the facility should 1. Follow specific instructions concerning fluid intake or restrictions. 2. Be accurate when recording fluid intake. The policy further indicated, 7. When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room. If the resident refuses to have the water pitcher removed, notify the supervisor and in turn, the physician. A review of Resident #162's admission Record revealed 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.
- Potential for harm · D2024-02-29 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and facility policy review, the facility failed to ensure 2 (Resident #54 and Resident #85) of 2 residents observed receiving medications via feeding tubes (gastrostomy or G-tube) received appropriate treatment and services to prevent feeding tube complications. Specifically, the facility failed to follow physician's orders to flush Resident #54 and Resident #85's G-tube between administration of medications. Findings included: A review of a facility policy titled, Administering Medications through an Enteral Tube, revised in November 2018, revealed that staff should 5. Administer each medication separately and flush between medications. 1. A review of Resident #54's admission Record revealed the facility admitted the resident on 08/10/2022 with diagnoses that included dysphagia (difficulty swallowing) following a cerebral infarction (stroke) and encounter for attention to gastrostomy. A review of Resident #54's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/2024, revealed the resident was in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-29 · 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 record review, interview, and document and policy review, the facility failed to ensure the attending physician documented adequate response to pharmacy monthly medication review irregularities for 1 (Resident #53) of 5 residents reviewed for unnecessary medications. Findings included: A review of a facility policy titled, Psychotropic Medication Use, dated July 2023, revealed 12. Psychotropic medications are not prescribed or given on a PRN [pro re nata; as needed] basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. A review of Resident #53's admission Record revealed the facility admitted the resident on 09/28/2022 with diagnoses that included anxiety disorder 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.
- Potential for harm · Dcited before2024-02-29 · 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 record review, interviews, and facility policy review, the facility failed to ensure orders for as-needed (pro re nata, PRN) psychotropic medications were limited to 14 days and failed to document a rationale for continued use and the intended duration when the medication extended beyond 14 days for 2 (Resident #2 and Resident #53) of 6 sampled residents reviewed for psychotropic medications. Findings included: A review of a facility policy titled, Psychotropic Medication Use, dated July 2022, revealed 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 1. A review of Resident #2's admission Record…
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 · D2023-12-08 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 and record review, the facility staff failed to communicate and collaborate with hospice (end of life care) staff about Resident 1's, recent fall, and increased level of pain, for one of three residents (Resident 1), reviewed for Falls. This failure resulted in inconsistent nursing services, which put Resident 1 at risk for diminished care and increased pain. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included vascular dementia (memory loss due to a decreased blood supply to the brain) and failure to thrive, per the facility's admission Record. On 11/20/23 Resident 1's clinical record was reviewed: According to the quarterly Minimum Data Set (MDS-a clinical assessment tool), dated 6/17/23, a cognitive score of 6 was listed, which indicated severe impaired cognition. The functional status indicated, total dependence for bathing and two staff required for bed mobility. According to the physician's order, dated 8/8/23, the resident was admitted to hospice.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to LINKS HEALTHCARE GROUP — 32 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.9 | +1.1 vs chain |
| Health inspection | 4 of 5 | 2.7 | +1.3 vs chain |
| Staffing | 3 of 5 | 2.7 | +0.3 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 31 homes this chain runs (chain average 2.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CLAWSON, SCOTT | Individual | INDIRECT OWNERSHIP INTEREST | since 06/01/2023 |
| EARL, STEVEN | Individual | INDIRECT OWNERSHIP INTEREST | since 06/01/2023 |
| SANOFSKY, JACK | Individual | INDIRECT OWNERSHIP INTEREST | since 06/01/2023 |
| RODRIGUEZ, CURTIS | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2023 |
| LINKS HEALTHCARE GROUP LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
| LINKS SUPPORT SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
| BERNHOLZ, VICTORIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2024 |
| CARTER, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2023 |
| DEGUZMAN, MYRNA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
| FROJELIN, ANTONETTE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
| MICHLIN, BERNARD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
| RAMIREZ, SHARON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
| RIVERA, REGINE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
| TILFORD, TOBY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2023 |
| WHITE, CURTIS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2023 |
| ANDERSON, CHAD | Individual | ADP OF THE SNF | since 06/01/2023 |
CMS files one row per role, so the 27 rows in the source record cover these 16 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.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 78% 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 $604K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 055873. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, 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.