The Vineyards Healthcare Center
76 Fenton Street, Livermore, CA 94550 · For profit - Corporation · 83 certified beds · (925) 443-1800 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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 | 5 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 improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 6.7% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.1% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.5% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.8% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.8% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 9.3% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.2% | 13.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 5.5% | 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 | 13.7% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.9% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.1% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.1% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.39 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.07 | 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.
60.6% 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 205 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 82.6% 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 0.79 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 60.6%CMS range 52.0–66.2 | 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 | 9.3%CMS range 6.3–12.3 | 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 | 82.6% | 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 | 84.9% | 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 | 83.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 1.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 4.5–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 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 83 beds and averages 77.3 residents a day — about 93% occupied, or roughly 6 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 4.16 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.73 hrs/resident/day on weekends vs 4.33 on weekdays — 14% thinner on weekends. RN hours go from 0.60 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 1 administrator has left in the past year.
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 unchanged from the previous inspection. 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.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · D2026-02-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 interviews and record reviews, the facility failed to provide care for Resident 1 that met professional standards of practice when:1. Resident's NPO status before PEG placement procedure was not verified with the physician (NPO is a medical abbreviation for the Latin phrase nil per os, which means nothing by mouth. It is a strict instruction from a doctor to not consume any food, liquids, or sometimes oral medications for a specific period, usually before surgery, PEG stands for Percutaneous Endoscopic Gastronomy. This is commonly referred to as a feeding tube that is placed directly into the stomach through the skin of the abdomen). 2. The resident's follow-up blood pressure (BP) readings were not obtained following administration of PRN blood pressure medication for seven occasions, and the physician was not notified of the interventions (PRN is a medical abbreviation for the Latin phrase pro re nata, meaning as needed).This failure resulted in Resident 1 in being transferred to the hospital 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 · D2026-02-02 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide an ongoing activity program to Resident 1 to ensure that she maintained her highest physical, mental and psychosocial well-being. This deficient practice placed Resident 1 at risk of sensory deprivation and social isolation. During an interview on 1/27/26, at 2:27 p.m., with Family Member (FM) 1, FM 1 stated she did not observe Resident 1 having any activities while the resident was still residing in the facility. Review of Resident 1's admission Record dated 1/29/26, indicated that the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (memory loss and impaired decision-making capacity). Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 9/26/25 under Section C, indicated Resident 1's short- term memory was impaired, and had moderately impaired…
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 before2024-12-06 · 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 the facility policy review, the facility failed to ensure food items were not stored on the floor in the dry storage room. This deficient practice affected all residents who received food from the kitchen. Findings included: An undated facility policy titled, Canned and Dry Goods Storage, revealed, All the food and non-food items purchased by the Department of Food and Nutrition services will be stored properly. The policy specified, 2. Food will be stored above the floor, on shelves, racks or other surfaces that facilitate thorough cleaning, best practice is using stainless steel shelving. Per the policy, Food and supplies should also be stored 6 inches off the floor. During an observation of the dry storage room on 12/02/2024 at 9:10 AM, the surveyor observed the following items on the floor: one case of potato pearls, two cases of poultry gravy mix, one case of dessert mix, one case of sandwich cookies, one case of pasta, two cases of juice, 10 cans of tomato soup, and one case of nectar thickened lemon water. During an interview on 12/02/2024…
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 · D2024-12-06 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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, and facility policy review, the facility failed to ensure a licensed nurse, who was not certified to perform cardiopulmonary resuscitation (CPR), did not perform CPR on a resident who had a do not resuscitate (DNR) code status. This deficient practice affected 1 (Resident #236) of 6 sampled residents reviewed for advance directives. Findings included: A facility policy titled, Emergency Procedure - Cardiopulmonary Resuscitation, revised 04/2016, indicated, 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is verified in CPR/BLS [cardiopulmonary resuscitation/basic life support] shall initiate CPR unless: a. It is known that a Do not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillator exists for that individual; or b. There are obvious signs of irreversible death. An admission Record indicated the facility admitted Resident #236 on [DATE]. According to 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 before2024-12-06 · 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, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions for 1 (Resident #14) of 2 sampled residents reviewed for urinary catheters. The facility further failed to ensure staff implemented contact precautions for 1 (Resident #26) of 3 sampled residents reviewed for transmission based precautions. Findings included: 1. A facility policy titled, Enhanced Barrier Precautions, revised 09/18/2024, indicated Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant (MDROs) to residents. 2. EBPs employ targeted gown and gloves during high contact resident care activities when contact precautions do not otherwise apply. a. Gown and gloves are applied prior to performing the high contact resident care activity (as opposed to before entering the room). The policy specified, 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs…
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 before2024-04-23 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedure for administering medications timely for one of three sampled residents (Resident 1), when Resident 1 ' s oral antibiotic medication (medication used to treat bacterial infections) was administered nine hours and sixteen minutes after it was ordered. This failure had the potential for exacerbating Resident 1 ' s health condition and compromising their overall health and well-being. Findings: During a review of Resident 1 ' s Administration Record (contains demographic and medical information), the administration record indicated, Resident 1 was admitted to the facility on [DATE], with diagnosis of COVID-19 (highly contagious respiratory disease), asthma (a chronic lung condition that makes it difficult to breathe) and hypertension (high blood pressure). Further review Resident 1 was discharged from the facility on February 25, 2024. During a review of Resident 1 ' s SBAR & initial COC/Alert Charting &…
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 · D2023-09-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to give appropriate care to Resident 1 ' s indwelling catheter tubing (a tube secured inside the bladder to drain urine into a bag outside the body). This failure resulted in Resident 1 having a urinary tract infection (UTI, an infection in any part of the urinary tract - kidneys, bladder, or urethra). Findings: A review of Resident 1's admission Record dated 7/14/23, indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of a history of UTI. A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care) dated 5/2/23, indicated the resident was usually able to understand others and usually understood by others. Resident 1 was totally dependent on one-person for toilet use (how resident cleanses self after elimination). Resident 1 had an indwelling urinary catheter, and the resident was always incontinent (unable to control) of bowel movement. A review of Resident 1's care plan titled, Indwelling…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-01 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure CNA 1 had the appropriate competencies and skills sets for providing proper care of the indwelling catheter (a tube secured inside the bladder to drain urine into a bag outside the body). This failure did not ensure Resident 1 received indwelling catheter care per physician's order and contributed to acquiring a urinary tract infection. (UTI), an infection in any part of the urinary tract - kidneys, bladder, or urethra. Findings: A review of Resident 1's admission Record dated 7/14/23, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of having a history of UTI. A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 5/2/23, indicated Resident 1 was totally dependent on one-person for toileting. The MDS also indicated Resident 1 had an indwelling urinary catheter and resident was always incontinent (unable to control) bowel movement. During a review of Resident 1 ' s physician ' 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 · D2023-08-04 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 received written notice before getting a new roommate. This failure resulted in emotional distress for Resident 1. Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility in July 2022 with diagnoses that included mild cognitive impairment, weakness, difficulty walking and need for assistance with personal care. Family Member (FM) 1 was listed as Resident 1's responsible party/resident representative. During a review of Resident 2's admission Record, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia, and cognitive communication deficit. During a concurrent interview and review of Resident 1's clinical record on 8/4/23 at 11:40 a.m. with Social Services Assistant (SSA), SSA stated after Resident 2's admission, Resident 2 was moved to Resident 1's room on 5/24/23. SSA…
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 before2021-07-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store, prepare and serve food safely when: 1. The following food items were not labeled with a delivery date or a use-by date: a. 5 containers of breadcrumbs b. 5 containers of grits c. 4 -1 pound (lb) bags of tortilla chips d. 3- 12 X 12 inch packs of rice crispy treats e. 2- 6 lb cans of pizza sauce f. 7- 11.5 ounce (oz) bottles of Real Mayonnaise g. 7 -12 oz bottles of yellow mustard h. Single use packets of mustard, tartar sauce, ketchup, [NAME] Mayo were in undated, transparent plastic containers. i. Assorted sugar-free single use jelly packs were in an undated box. 2. There was no air gap (amount of space that separates a water line from an ice machine drain to a sewer) for the ice machine to prevent potential backflow (water from flowing back up a water line). These failures had the potential to cause food-borne illness for 79 of 80 residents. Findings: 1. On 7/26/21 at 9:50 a.m., during a concurrent kitchen observation 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.
Show the remaining 14 citations
- Potential for harm · Dcited before2021-07-30 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of four sampled residents (Resident 58), the facility failed to ensure the Minimum Data Set (MDS, an assessment tool used to direct care) admission Assessment for Resident 58's oxygen use was coded accurately. This failure resulted in the MDS containing inaccurate information regarding Resident 58's respiratory status and oxygen use. Findings: During a review of Resident 58's admission Record, dated July 29, 2021, the admission Record indicated, Resident 58 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia (person is unable to exchange oxygen properly in the lungs), chronic obstructive pulmonary disease (COPD, a progressive lung condition that makes it harder to breathe over time,, and congestive heart failure (CHF), the heart's inability to properly circulate blood. Review of Resident 58's Order Listing Report dated July 29, 2021, indicated the physician order dated 7/28/21, Oxygen (O2) at 2 liters/minute or…
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 · D2021-07-30 · 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, for two of three sampled residents (Resident 48 and Resident 58), the facility failed to post a safety sign indicating, Oxygen in Use outside the shared room of Residents 48 and 58. Both residents used oxygen concentrators (a portable medical device used to deliver oxygen to those who have a condition that caused or resulted in low levels of oxygen in their blood). This failure resulted in no cautionary sign warning others that oxygen (accelerates combustion in the presence of a flammable substance or smoking) was in use and refrain from certain activity or products to avoid a potential fire hazard. Findings: During an observation on 7/26/21, at 11:20 a.m., inside Resident 48 and Resident 58's shared room, both residents were receiving oxygen use via nasal cannula (tube with prongs placed into the nostrils) delivered through an oxygen concentrator. During an interview after the observation, with the Licensed Vocational Nurse (LVN) 1 on 7/26/21, LVN 1 stated there was no Oxygen in Use sign at the room entrance door or on top 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 · E2019-02-07 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 treat four of four sampled residents (Residents 41, 45, 33, and 3) with respect and dignity when: 1. Resident 41 and Resident 45's urinary drainage bags were exposed, uncovered and hung on the side of their beds. 2. Staff stood over Resident 33 while assisting her with breakfast. 3. Resident 3 had his lunch tray uncovered in front of him and was not assisted with his meal for 20 minutes while staff assisted his tablemate resulting in Resident 3 feeling anxious and ignored. These failures had the potential for Residents 3, 41, 45, and 33 to feel humiliated and disrespected while receiving care. Findings: 1. During a facility observation on 2/4/19 at 8 a.m., Residents 41 and 45 (who were roommates) were lying in their beds. Both Residents 41 and 45 had urinary drainage bags containing urine hanging on the side of their beds facing the door which was visible from the hallway where visitors and other residents passed by. During an interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-02-07 · 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, serve and prepare food under sanitary conditions when the resident refrigerator contained expired food and food with no open and use-by-dates, the dry storage room contained food with no open and use-by-dates, scoops and measuring cups were stored dirty, and expired nutritional powder was stored in the utility room. These deficient practices had the potential to place residents at risk for foodborne illnesses and possibly result in unmet nutritional needs. Findings: During an initial observation of the facility's Dietary Department on 2/4/19 from 8:15 a.m. until 10:00 a.m., the following was observed: 1. In the walk-in resident refrigerator at 8:15 a.m.: a. Five 32 ounce cartons of Imperial Thickened Dairy Drinks were expired on 1/16/19. b. A bag containing seven boiled eggs was labeled with an expiration date of 1/8/19. c. One block of one and a half pounds Provolone Imperial Sliced Block and Barrel Cheese had an expiration date of 4/2018. d. One 15 pound case of Hormel Bacon had no open date and no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-02-07 · tag F0880 — failed to prevent and control infections — patternProvide 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 perform proper handwashing while providing care to three (Residents 56, 41, and 2) of six sampled residents. Thess failures had the potential to result in the spread of infectious organisms not only to Residents 41, 56, and 2, but to other residents, staff and visitors at the facility. Findings: 1. During an observation of the facility on 2/4/19 at 1:00 p.m., the Social Services Director (SSD) was observed coming out of Resident 56's room. The SSD walked into the hallway, around a corner, and to a food cart parked in the hallway. SSD opened the food cart and placed her hands on a tray inside of it. The SSD was observed not to have washed her hands after exiting Resident 56's room. In an interview on 2/4/19 at 1:00 p.m., the SSD stated I know I should have washed my hands when I came out of the resident's room. 2. During an observation of Resident 41's wound care treatment on 2/5/19 at 10:29 a.m., the Licensed Vocational Nurse (LVN 3)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-07 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
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 complete quarterly assessments for one (Residents 49) of one sampled residents. This failure had the potential to cause residents not to have their medical and/or psychosocial needs met. Findings: Review of the Minimum Data Set (MDS - an assessment tool used to help determine health care needs) dated 12/30/18 showed Resident 49 was admitted to the facility on [DATE]. Review of the clinical record for Resident 49 showed a care plan dated 7/17/2017 indicating, Resident 49 has impaired cognitive function or impaired thought processes related to dementia as evidenced by confusion and forgetfulness. Continued review of Resident 49's clinical record did not show social service quarterly assessments for the Assessment Reference Dates (ARD) of 9/29/2018 and 12/30/18. During an interview with the Social Services Director (SSD) on 2/6/19 at 12:18 p.m., the SSD found an assessment dated [DATE], however, could not find a quarterly assessment for the month 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 · D2019-02-07 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 record review and interview, the facility failed to send a discharge assessment for one (Resident 1) of one residents to the Centers for Medicare/Medicaid Services (CMS) within fourteen days after being discharged from the facility. This failure resulted in CMS not receiving discharge data for Resident 1. Findings: Review of Resident 1's admission Minimum Data Set (MDS - an assessment tool used to assist in the directing of health care needs) dated 8/13/18 showed Resident 1 was admitted to the facility on [DATE]. Review of the clinical record for Resident 1 showed Resident 1 was discharged from the facility on 10/5/18, however the MDS did not show completion of the discharge section. During a concurrent interview and review of the medical record while in the presence of the MDS Coordinator (MDSC), the Administrator (ADM) and the Director of Nursing (DON) on 2/7/19 at 9:01 a.m., the MDSC stated the discharge MDS was not done, could not be found, was late, and should have been completed within 14 days…
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 before2019-02-07 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 document the fall history of one (Resident 49) of one resident when the number of falls that caused injury to Resident 49 was not recorded accurately in the Minimum Data Set (MDS - an assessment tool used to assist in the directing of health care needs). This failure resulted in the MDS containing inaccurate information regarding Resident 49's history of falls with injuries and had the potential of not providing interventions that met the needs of Resident 49. Findings: Review of Resident 49's quarterly MDS dated [DATE] showed Resident 49 was admitted to the facility on [DATE]. Further review of the MDS showed that Resident 49 had two or more falls since admission to the facility, however indicated that Resident 49 had no falls were with injuries. Review of a separate quarterly MDS dated for 12/30/18 showed Resident 49 had not fallen since admission or prior to the last quarterly assessment (9/29/18). Review of Resident 49's medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-07 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 update one (Resident 49) of one sampled resident's care plans every quarter and/or as needed. This failure had the potential to result in Resident 49 not having his health care needs fully provided for. Findings: Review of the Minimum Data Set (MDS - an assessment tool used to assist in directing health care needs) dated 12/30/18 showed Resident 49 was admitted to the facility on [DATE]. Review of the clinical record for Resident 49 showed the following social services care plans: a. Resident 49 was an elopement risk and wandered around the facility; revised on 7/2/17. b. Resident 49 has a behavior problem related to major depression, Dementia with behavioral disturbances, anxiety disorder; revised on 8/17/17. c. Resident 49 had impaired cognitive function or impaired thought processes related to dementia as evidenced by confusion and forgetfulness; revised on 9/2/17. d. Resident was at risk for falls related to a diagnosis of Dementia and Obsessive…
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 before2019-02-07 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for one (Resident 61) of four sampled residents, the facility failed to provide medications to meet the needs of the resident when the facility did not order medications in a timely manner. This failure resulted in Resident 61 not getting her medications as ordered by her physician for her health care needs. Findings: Review of the medical record on 2/5/19 indicated Resident 61 was admitted to the facility on [DATE] with multiple diagnoses which included fracture of unspecified part of neck right femur (thigh bone) and diabetes mellitus 2 with neuropathy (condition of nerve damage caused due to persistently high blood sugar level). During a medication pass observation on 2/5/19 at 8:55 am, Licensed Vocational Nurse (LVN 2) prepared and administered a total of 11 oral medications, one medication to be administered as an injection, one medication to be used as an inhaler, and one medication to be administered by nasal spray for Resident 61. Review and comparison…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-02-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was below five percent. There were three errors out of 29 opportunities during medication administration. These failures resulted in a medication error rate of 10.34 percent and had the potential for placing residents at risk for undesired health care outcomes. Findings: Review of Resident 61's admission Record on 2/5/19 indicated Resident 61 was admitted to the facility on [DATE] with multiple diagnoses which included fracture of unspecified part of neck right femur (thigh bone) and diabetes mellitus 2 with neuropathy (condition of nerve damage caused by persistently high blood sugar level). During a medication pass observation on 2/5/19 at 8:55 am, Licensed Vocational Nurse (LVN 2) prepared and administered a total of 11 oral medications, one medication to be administered as an injection, one medication to be used as an inhaler, and one medication to be administered by nasal spray for Resident 61.…
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 · Bcited before2024-12-06 · 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, document review, and facility policy review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 18 (Rooms 100, 102, 104, 106, 108, 110, 112, 114, 118, 120, 122, 124, 126, 128, 130, 134, 136, and 138) of 30 resident rooms in the facility. Findings included: During an interview on 12/04/2024 at 10:30 AM, Resident #2 stated they did not have enough space in their room. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/09/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During an interview on 12/04/2024 at 10:32 AM, Resident #21 stated they did not have enough space in their room. A quarterly MDS, with an ARD of 09/23/2024, revealed Resident #21 had a BIMS score of 15, which indicated the resident had intact cognition. During a concurrent review of a document titled Client Accommodation Analysis, and observation…
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 · Bcited before2021-07-30 · 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 and interview, the facility failed to provide 55 of 55 residents in the following multiple occupancy resident rooms (100, 102, 104, 106, 108, 110, 112, 114, 118, 120, 122, 124, 126, 128, 130, 134, 136, 138, and 140 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 of the facility on 7/29/21 at 11:20 a.m., the Maintenance Supervisor (MS), measured the facility rooms. Based on those measurements, the following rooms were determined to have less than the required 80 sq ft per bed. Room Numbers: 100, 102, 104, 106, 108, 110, 112, 114, 118, 120, 122, 124, and 126 measured room size was 220 sq ft and 73 sq ft per resident for these three occupancy rooms. room [ROOM NUMBER] measured room size was 281 sq ft and 70 sq ft per resident in the four occupancy room. Room…
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 · Bcited before2019-02-07 · 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 — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure multiple resident rooms (100, 102, 104, 106, 108, 110, 112, 114, 118, 120, 122, 124, 126, 128, 130, 134, 136, 138, 140) had at least 80 square feet (sq ft) per resident. This failure had the potential to compromise the provision of care residents receive. Findings: During an observation of the facility on 2/4/19 at 9 a.m., the Maintenance Director measured the facility rooms. Based on those measurements, the following rooms were determined to have less than the required 80 sq ft per bed. Room Numbers: 100, 102, 104, 106, 108, 110, 112, 114, 118, 120, 122, 124, 126, 128, 130, 134, 136, 138, 140. During an interview with the Administrator on 2/4/19 at 10 a.m., the Administrator acknowledged the rooms were less than 80 sq ft per resident bed and stated we are providing good care to our residents. During several random interviews with residents, there were no complaints regarding the space of the room for personal items nor was resident care adversely impacted. Granting of room size waiver recommended.
“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 | 5 of 5 | 2.9 | +2.1 vs chain |
| Health inspection | 5 of 5 | 2.7 | +2.3 vs chain |
| Staffing | 3 of 5 | 2.7 | +0.3 vs chain |
| Quality measures | 5 of 5 | 4.1 | +0.9 vs chain |
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 |
|---|---|---|---|
| LINKS HEALTHCARE GROUP LLC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/06/2025 |
| AMERICAN RIVER HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/01/2021 |
| FORBRIGHT BANK | Organization | INDIRECT OWNERSHIP INTEREST | since 09/01/2017 |
| CLAWSON, SCOTT | Individual | INDIRECT OWNERSHIP INTEREST | since 09/01/2017 |
| EARL, STEVEN | Individual | INDIRECT OWNERSHIP INTEREST | since 09/01/2017 |
| RODRIGUEZ, CURTIS | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2017 |
| SANOFSKY, JACK | Individual | INDIRECT OWNERSHIP INTEREST | since 09/01/2017 |
| TILFORD, TOBY | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2017 |
| LINKS SUPPORT SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/20/2025 |
| FOSTER, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2017 |
| MARWAHA, JATINDER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/02/2017 |
| YELASCO, JASCHA AMEDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2017 |
CMS files one row per role, so the 22 rows in the source record cover these 12 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.
4 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.
This home reported $750K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 055212. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-06, 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.