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Fairmont Rehabilitation Hospital

950 S. Fairmont Avenue, Lodi, CA 95240 · For profit - Corporation · 59 certified beds · (209) 368-0693 Medicare & Medicaid certified

Call the home — (209) 368-0693 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Jan 2026Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Urgent care / clinic
1235 W Vine St Ste 20 · (209) 339-7600 · Call to confirm hours
Pharmacy
1121 W Vine St · (209) 625-8633 · Call to confirm hours
Grocery
1230 S Fairmont Ave · (209) 334-2081 · Call to confirm hours
Park
Kofu Park0.2 mi
1145 S Ham Ln · (209) 333-6742 · Typically dawn to dusk
Place of worship
760 S Ham Ln · (209) 426-5383

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased19.0%10.2%15.4%worse
Long-stay residents who lose too much weight3.1%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms13.4%7.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury6.5%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened21.7%9.8%16.1%worse
Long-stay residents on antianxiety or hypnotic medication22.8%13.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers6.2%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control25.4%10.2%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table1.3%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine98.7%93.2%79.4%better
Short-stay residents rehospitalized after admission20.0%23.0%22.6%better
Short-stay residents with an outpatient ER visit14.6%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.462.251.67better
Long-stay outpatient ER visits per 1,000 resident days1.101.571.80better

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.

62.1% 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 337 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.1%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
55.9%U.S. median 56.6%
Met the expected recovery
0.78U.S. median 0.31
Therapy hours / resident / day
0.46hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 55.9% 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 161 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 0.78 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 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.1%CMS range 56.9–66.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 9.2–14.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge55.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge55.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge47.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS 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 dischargenot 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 stay1.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.6%CMS range 4.5–9.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.181.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.51
RN hours/ resident / day
1.52
LPN hours/ resident / day
2.51
Aide hours/ resident / day
4.55
Total nurse hours/ resident / day
0.42
RN hoursweekends
34.7%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 59 beds and averages 54.6 residents a day — about 93% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.51 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 4.00 hrs/resident/day on weekends vs 4.77 on weekdays — 16% thinner on weekends. RN hours go from 0.55 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% 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

8
deficiencies at the latest standard inspection (2026-05-07)
9
at the previous standard inspection (2025-01-16)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · Fcited before2026-05-07 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in food handling, storage, and preparation areas for 53 residents who received meals from the kitchen when:1. Debris was present inside the clean utensils drawer;2. Mold was found inside a bag of cherries stored in the refrigerator;3. Cereal container lids were found loose;4. An opened box of iced tea bags in the dry goods area contained a plastic bag with a hole;5. Four spice containers were observed with lids that were open and could not be closed;6. Two large spice containers with screw-top lids were not tightly sealed;7. The casserole scalloped potatoes box was not properly sealed;8. Inconsistent food labeling was observed, including multiple opened liquid seasonings and sweetener that lacked open-by-dates; 9. Wet snack containers were found stacked in a cabinet;10. The food preparation table was found with debris and dust accumulation;11. One cutting board was in use in the kitchen, limiting the ability to properly clean and sanitize between tasks;12. The oven/range was found…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to promote, maintain, and protect the dignity and privacy for one of eighteen sampled residents (Resident 5) when: 1. Certified Nursing Assistant (CNA) 1 did not fully close the privacy curtain during a bed bath, resulting in Resident 5's body being exposed and visible from the hallway; and, 2. Resident 5's nephrostomy (a thin, flexible tube is inserted through the skin of your lower back directly into your kidney to drain urine) drainage bag (urinary bag) was not covered with a dignity bag (privacy bag). These deficient practices resulted in unnecessary exposure of Resident 5 during care and had the potential for loss of privacy and dignity, and increased psychosocial distress (embarrassment, anxiety and feelings of humiliation). Findings: During a review of Resident 5's clinical record titled, FACE SHEET, dated 5/6/26, the record indicated Resident 5 with diagnoses that included, but were not limited to, hydronephrosis with renal and ureteral calculous obstruction ( kidney swelling secondary to kidney stones…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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 accommodate the needs of 1 of 18 sampled residents (Resident 68) when Resident 68's call light (devices used to contact staff for assistance) was not within his reach.This failure placed Resident 68 at increased risk for unmet care needs, delayed staff response, falls, and increased the potential for accidents or injury.Findings:During a review of Resident 68's clinical record titled, Face Sheet, dated 5/6/26, the record indicated that Resident 68 had diagnoses that included, but were not limited to, need for assistance with personal care, hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke, a sudden lack of oxygen to the brain) affecting the right dominant side, muscle weakness, aphasia (a language disorder caused by brain damage most commonly from a stroke that impairs the ability to speak, write, and understand language), and dysphagia (difficulty swallowing, indicating a disruption in the process of moving food 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    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 act upon the concerns brought forth from the Resident Council (a group of residents that meet and discuss concerns monthly) when Resident Council concerns of call lights not being answered timely, call lights being wrapped around the bed frame, staff speaking another language, and staff not fully completing Activities of Daily Living (ADL- these are the fundamental, routine self-care tasks individuals perform daily such as eating, bathing, dressing, toileting, and moving around) care before leaving the room were not addressed by the facility in a timely manner.This failure resulted in residents declining to attend the Resident Council meeting scheduled on 3/24/26 and feeling that issues brought forth in Resident Council meetings were not being addressed. Findings: During a review of Resident 23's clinical record titled, Face Sheet, dated 5/7/26, the record indicated that Resident 23 was admitted to the facility in 2025 with diagnoses which included muscle weakness, type 2 diabetes mellitus (a chronic…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to implement a fall intervention for 1 of 18 sampled residents (Resident 8), when fall mat was not placed at Resident 8's bedside. This failure had the potential for Resident 8 to sustain further falls with injury. Findings:A review of Resident 8's admission Record indicated Resident 8 was admitted to the facility in 2025 with diagnoses which included chronic obstructive pulmonary disease (a progressive, treatable, but generally irreversible lung condition that restricts airflow, making it hard to breathe), schizophrenia (a chronic and severe brain disorder that affects how a person thinks, feels, and acts, often causing them to struggle with distinguishing reality from fantasy), and anxiety disorder (serious, treatable mental health conditions characterized by excessive, persistent fear or worry that interferes with daily life).A review of Resident 8's Minimum Data Set (MDS - an assessment tool), dated 1/12/26, Resident 8 scored 0 out of 15 in a Brief Interview for Mental Status (BIMS) which indicated she had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 interview and record review, the facility failed to maintain accurate and complete records for one of eighteen sampled residents (Resident 5) when, Resident 5's allergy to Levaquin (an antibiotic medication used to kill bacteria causing illness) was not updated in Resident 5's allergy profile, Resident 5 was ordered and administered Levaquin, and there was no documentation regarding communication with the ordering provider regarding the allergy, no documentation of an IDT (interdisciplinary team; a group of healthcare professionals) meeting discussing the medication allergy, or monitoring of any adverse reactions to the medication. This deficient practice had the potential to place Resident 5 at risk for adverse reactions and the care and services provided would not be known across all disciplines to assist in making medical decisions for Resident 5. Findings:During a review of Resident 5's clinical record titled, Face Sheet, dated 5/7/26, the record indicated the resident was admitted to 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-07 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 53 residents when Resident 67's urinal (portable, handheld containers designed for men with limited mobility to urinate while in bed or seated) was not labeled with identifying information.This failure had the potential to spread infection and cause health problems to the residents in the facility.Findings:During a review of Resident 67's clinical record titled, Face Sheet, dated 5/6/26, the record indicated that Resident 67 had diagnoses that included, but were not limited to, need for assistance with personal care, hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting right dominant side (a type of ischemic stroke, accounting for about 80% of all strokes, caused by blocked blood flow to the brain, leading to tissue death [necrosis]).During a concurrent observation and interview on 5/4/26 at 10:33 AM with Certified Nurse Assistant (CNA) 3, Resident 67's urinal was observed. CNA 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to submit a summary of investigation for an alleged resident to resident altercation to the Department within five (5) working days, as required, for one of three sampled residents (Resident 1).This failure placed Resident 1 at risk for further resident to resident altercations.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to thefacility with diagnoses including unspecified dementia (ongoing problems with memory and thinking), chronic kidney disease (long term kidney damage), other symptoms and signs involving cognitive (the brain's mental processes of acquiring knowledge, understanding, and thinking) functions and awareness.Review of Resident 5's admission RECORD, indicated Resident 5 was admitted to thefacility with diagnoses including orthopedic aftercare (care and recovery support after bone, joint, or muscle surgery or injury), displaced intertrochanteric fracture of right femur (broken upper thigh bone near the hip), history of falling, abnormalities of gait and mobility, type 2…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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

    Based on interview, and record review, the facility failed to develop and implement a comprehensive care plan (written plan that guides staff on daily care and safety based on the resident's needs) for one of three sampled residents (Resident 1) to address Resident 1's frequent and extended use of a shared bathroom, which delayed other residents' access to the bathroom.This failure resulted in dissatisfaction among those residents and placed Resident 1 at potential risk for further altercations with other residents.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including unspecified dementia (ongoing problems with memory and thinking), chronic kidney disease (long term kidney damage), other symptoms and signs involving cognitive (the brain's mental processes of acquiring knowledge, understanding, and thinking) functions and awareness. Review of the document titled, Report of Suspected Dependent Adult/Elder Abuse, completed and submitted to the Department on 11/8/25 by the Social Service Director (SSD), indicated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-07-02 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella (a serious lung infection) and other opportunistic waterborne pathogens (a microorganism [bacteria] that exists in water sources or plumbing [pipes required for the water supply, heating and sanitation in a building] systems that can cause serious illness in people over [AGE] years of age and have weakened immune systems) for a census of 54 when: a. The facility did not complete and document a facility-wide assessment of potential Legionella growth areas to include flow chart, b. The facility did not implement adequate control measures, c. The facility did not establish sufficient monitoring protocols; and, d. The facility did not create an intervention plan for when control limits are not met. These failures put the residents and staff at risk of potential Legionella and other opportunistic waterborne…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Dcited beforedisputed · IDR2025-06-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure an environment free of accidents or hazards for one of four residents (Resident 2) when Resident 2, who was at high risk for falls, fell when she was left in the bathroom unattended on 8/5/24. This failure had the potential to result in Resident 2 sustaining injury including fractures (broken bones) and decreased well-being.Findings:A review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility in 2024 with diagnoses which included surgical repair of left hip fracture.A review of Resident 2's Care Plan Report, dated 7/27/24, indicated .Focus.At risk for falls.Goal.Will not sustain serious injury.Interventions.Anticipate and meet needs.A review of Resident 2's Progress Notes, dated 8/5/24, indicated, .writer was called by attending CNA (Certified Nursing Assistant) to pull up resident @ 0600 [6AM].upon entering room, resident was found sitting down inside the bathroom.resident transferred back to wc [wheelchair] by 3 person assist.resident stated that she needed to use…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-07 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure dietary staff served the correct meal portions for two of four sampled residents (Resident 2 and Resident 3) when, 1. Resident 2 did not receive their prescribed small portion diet during the lunch meal on 5/7/25. 2. Resident 3 did not receive their prescribed small portion diet during the lunch meal on 5/7/25. This failure had the potential to contribute to unplanned weight gain which could negatively impact the health and wellbeing of Resident 2 and Resident 3. Findings: 1. During a review of Resident 2 ' s admission RECORD, the document indicated Resident 2 was admitted to the facility in early 2020. A review of Resident 2 ' s BIMS [Brief Interview for Mental Status; a screening tool used to assess for cognitive impairment], dated 3/18/25, indicated Resident 2 had a BIMS score of 15 (a score of 13 to 15 points suggested that cognition was intact). A review of Resident 2 ' s Order Listing Report, dated 1/19/24, indicated, .NAS [No Added Salt] diet .*Small Portions on all meals* . A review of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-01-16 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure safe food storage and production in accordance with professional standards of food safety for the 56 residents who received prepared food from the kitchen when: 1. Open food packages (one bag of bran cereal, one bag of biscuit mix, and a five-gallon storage bin with about two-gallons of rice) were not labeled with a use by date; and, 2. Wet plate covers were stacked together. These failures had the potential to expose residents to food borne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview on 1/13/25, at 8:47 a.m., in the kitchen accompanied by the Dietary Manager (DM), the following findings were observed: 1. a. An opened clear plastic bag containing bran cereal was not labeled with a use by date. The DM stated the bag should have been labeled with a use by date. 1.b. A five-gallon storage bin with about two-gallons of rice was not labeled with a use by date. The DM confirmed the rice was not in the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-16 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    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 safe use of facility owned smart phones (also known as cell phones) for communication with medical providers regarding resident's Protected Health Information (or PHI, refers to any individually identifiable health information about a resident) with a census of 56 residents. This unsafe practice could compromise residents' private medical information and violate residents' health information privacy and confidentiality. Findings: During a concurrent inspection of the facility's Station 2 medication storage areas and interview with Licensed Nurse (LN) 7, on 1/13/25, at 10:26 AM, a smart phone marked with Nurse Station 2, 209-3 . [phone number]) was noticed sitting unattended next to a computer at the station. LN 7 stated the phone was used to communicate with medical providers. When LN 7 unlocked the screen, the review of text messages communicated with different doctors and nursing staff, indicated the staff sent resident's health…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-16 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure safe medication storage practices in the medication room (a locked room used to store medications and supplies) and one out of six medication carts (a mobile cart stored medication and supplies for immediate use), and medication refrigerator when: 1. Medication Cart 2 in Station 2 stored undated inhalation medication called Ipratropium/Albuterol (or DuoNeb, an inhalation solution used to treat breathing problems); 2. Medication Closet 1 in Station 1, in the active storage areas, stored expired test tubes (A blood test tube is a sterile, vacuum-sealed tube used to collect and store blood samples for medical testing); and 3. Medication refrigerator in Station 2 contained an opened and undated vial of Aplisol (or Tuberculin Purified Protein Derivative [PPD] a testing agent used to diagnose Tuberculosis or [TB], a serious lung disease) and an expired container of Golytely liquid (a solution used to prepare the colon for medical…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 safety of bed side medication storage and use for 1 out of 10 residents (Resident 24) observed for medication administration based on facility's policy and medical doctor's orders. This failed practice resulted in unauthorize use of medications without a doctor's order in the facility, unsafe handling, and storage of medications in a room shared with another resident. Findings: During a medication administration observation for Resident 24, at facility's station 2 hallway, accompanied by Licensed Nurse (LN) 3, on 1/13/25, at 9:35 AM, LN 3 administered the morning medications and later at 9:56 AM measured the Blood Pressure (BP) and gave the two blood pressure medications. Resident 24 was sitting in a wheelchair and was hard of hearing. Further observation, inside Resident 24's room, there were three medications with no labels stored on top of Resident 24's bed-side table During a concurrent observation and interview with LN 3, in Resident 24's room, on 1/13/25, at 1:22 PM, the bed side unlabeled…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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

    Based on observation, interview, and record review the facility failed to ensure safe cleaning and sanitization of shared glucometer (a device used to measure blood sugar) in-between resident care for two residents out of nine residents observed for medication administration (Resident 39 and Resident 10) based on facility's policy and manufacturer specifications. This failure had potential to spread infection among residents and compromise resident's well-being. Findings: During a medication administration observation with Licensed Nurse 2 (LN 2), at Station 2 hallway, on 1/14/25, at 12:08 PM, LN 2 with gloved hand took the glucometer and supplies in the Resident 39's room to measure the blood sugar. LN 2 placed the glucometer on the bedside table then poked Resident 39's right middle finger with a lancet (small, sharp needles used to obtain a small amount of blood from the finger for blood sugar testing) to get the blood and soaked the test strip (a plastic strip contains chemicals to help with blood sugar measurement) with blood to measure the blood sugar. LN 2 used one…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the prescription medication delivery manifests (delivery manifest, also known as a shipping manifest, is a legal document that listed all items being transported in a shipment) which included narcotic controlled medications (medication with risk of abuse including opioids) were signed by licensed staff upon delivery from the provider pharmacy for a census of 56 residents. This failed practice may contribute to unsafe medication handling and risk of drug diversion (unlawful use or abuse of medication). Findings: During a medication area inspection, at facility's Station 1, on 1/13/25, at 10:36 AM, accompanied by Licensed Nurse (LN) 6, a binder which contained the delivery sheets for prescription and narcotic medications delivery, were not consistently signed by nursing staff upon receipt from the provider pharmacy delivery driver. The individual sheets titled Packing Slip, at the bottom on each page, indicated .By signing below you acknowledge that you have received this pharmacy shipment. Please fax…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation, and record review, the facility failed to ensure the safe use of psychotropic medications (mind altering drugs) for one of five residents (Resident 44) selected for unnecessary medication use when: 1. Resident 44's documented diagnosis of bipolar disorder (a chronic mood disorder which causes intense shifts in mood, energy levels and behavior) in the medical record for use of aripiprazole (a drug used to treat mental health issues) was not reflected in the medical doctor's progress notes, History and Physical (H&P), and previous hospitalization record; and 2. Resident 44's mental health consult and mental health medication adjustments were not carried out, nor communicated to the primary Medical Doctor (MD) 1, the Director of Nursing (DON), the licensed nursing (LN) staff, and the Resident Representative (RP, individual responsible for maing healthcare decisions on behalf of resident). These failures could contribute to unsafe use of mind-altering medications and the inaccurate diagnosis could lead to unnecessary use of medications with adverse…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with the census of 56 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 2 errors out of 30 opportunities which resulted in a facility wide medication error rate of 6.67% in two out of 10 residents (Resident 5 and Resident 10) during medication administration observation. These failures could contribute to unsafe medications use, medication error, and not following the doctor's orders. Findings: 1. During a medication pass observation, with Licensed Nurse 1 (LN 1), at facility's Station 2 hallway, on 1/13/25, at 8:49 AM, LN 1 offered Resident 5 the morning pills including 7 medications along with nutritional supplement. Resident 5 chose to take only 4 of her medications with her own coffee already on her side table. Resident 5…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 412) was free from significant medication errors when vitamin D3 (supplement for low vitamin D levels in the blood) oral capsule 50,000 UT (UT-units is a unit of measurement) was administered daily from 10/26/24 to 12/26/24. This deficient practice placed Resident 412 at risk of vitamin D toxicity. Findings: During a review of Resident 412's physician order dated 10/25/2024, the order indicated, Vitamin D3 Oral Capsule 50,000 UT .Give one capsule by mouth one time a day .Every day. During a concurrent interview and record review on 1/15/25 at 1:17 PM with the pharmacy consultant (PC), the PC confirmed that a medication regimen review (MRR, reviewing medications of residents for effectiveness and safety) was done in October, November, and December 2024 for Resident 412. The PC further stated, If I had caught this in real time my recommendation would have been to reduce the dose and request labs for Vitamin D levels. The PC stated excess Vitamin D3 could cause nausea, vomiting,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure nursing staff followed infection prevention practices and the required Enhanced Barrier Precaution (or EBP, an infection control strategy used in healthcare settings, particularly nursing homes, to reduce the spread of infection by requiring healthcare workers to wear gowns and gloves during high-contact resident care activities) guideline when the Intravenous (or IV, Into the Vein) line was used to administer IV antibiotic in one out of 10 residents observed for medication administration (Resident 47). This failed practice could contribute to unsafe medication use and spread of infection into Resident 47's blood stream. Findings: During a medication administration observation, with Licensed Nurse 5 (LN 5), at Station 2 hallway, on 1/13/25, at 11:51 AM, LN 5 gathered Resident 47's IV antibiotic and supplies in a plastic bin and entered the room with gloved hand, no gown and her mask was worn below her nose. Resident 47's room was marked by a posted sign, at the wall next to the door, indicating…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-12 · tag F0694 — pattern
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to perform and document baseline and follow-up measurements of a PICC Line (peripherally inserted central catheter: a long, flexible tube inserted into one of the veins in the upper arm and used to deliver medication) external length and right upper arm circumference (distance around upper arm) for one of 16 sampled residents (Resident 54). This failure had the potential to result in Resident 54 having unidentified complications of right arm swelling and, dislodgement, occlusion, and leakage of the PICC line when it was not monitored. Findings: During a review of Resident 54's admission records, the records indicated Resident 54 was admitted to the facility in 2023 with diagnoses including sepsis (body's overactive and extreme response to an infection), bacteremia (bacteria in the blood), and Methicillin Resistant Staphylococcus Aureus Infection (MRSA, a bacteria that causes infections in different parts of the body). During a review of Residents 54's clinical records, there was no documented evidence 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-12 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure E-kits (emergency medications) were replaced in a timely manner when medications were removed for a census of 55. This failure had the potential risk for residents not to receive medications in a timely manner and worsen their medical conditions. Findings: During a concurrent observation and interview on 1/9/24 at 1:18 a.m., with Director of Nursing (DON) at Nursing Station One Medication Closet One, an Oral E-kit was identified sealed with a red plastic tie, indicating it had been opened by nursing staff. Inside the oral E-kit were three E-kit logs (a document completed by nursing staff whenever a medication is removed from the emergency supply), with entries into the kit documented on 1/4/24 at 7:30 a.m., 1/5/24 at 8 a.m., and 1/5/24 at 7:30 p.m. DON stated once a medication was removed from the E-kit, nursing staff were expected to notify the pharmacy and have it replaced within 24 to 48 hours. During a concurrent observation and interview on 1/9/24 at 11:54 a.m., with DON at Nursing Station Two…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-12 · tag F0790 — failed to provide dental care — pattern
    Provide routine and 24-hour emergency dental care for each resident.
    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 dental services were provided for one of 16 sampled residents (Resident 3) in a timely manner, when there was no follow up regarding Resident 3's authorization for a set of dentures for over four (4) months. This failure resulted in delay of dental services for Resident 3 and placed the resident at risk for oral pain related to inability to effectively chew foods and had the potential risk for unintended weight loss. Findings: A review of the admission Record indicated the facility admitted Resident 3 in 2022 with multiple diagnoses including depression and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situation). A review of Resident 3's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 10/10/23, indicated Resident 3 was cognitively intact. The MDS assessment indicated Resident 3 had no natural teeth or tooth fragments (edentulous). A review of Resident 3's physician order dated 10/4/22 indicated, May have dental consult with follow up…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-12 · tag F0641 — isolated
    Ensure 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 ensure one of 16 sampled residents (Resident 25) received an accurate assessment, reflective of the resident's status at the time of the assessment, including hearing assessment. Resident 25 had hearing loss and used hearing aids, however, the Minimum Data Set (MDS, an assessment and care screening tool) did not code the use of hearing aids. This failure contributed to facility's inability to develop and implement an individualized care plan related to Resident 25's use of hearing aids, which could negatively affect the resident's communication with staff and impact her quality of life. Findings: A review of the admission Record indicated Resident 25 was admitted to the facility in 2023 with multiple diagnoses which included generalized muscle weakness and pneumonia. A review of Resident 25's hearing assessment documented in the 'Initial admission Record' dated 11/15/23, indicated the resident had hearing aids. A review of Resident 25'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-12 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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

    Based on observation, interview, and record review, the facility failed to observe professional standards of nursing practice for one of 16 sampled residents (Resident 25) when the use of hearing aids was not monitored as directed by the physician. This failure had the potential to affect Resident 25's ability to communicate with staff and negatively impact the resident's quality of life. Findings: A review of the admission Record indicated Resident 25 was admitted to the facility in 2023 with multiple diagnoses which included generalized muscle weakness and pneumonia. A review of Resident 25's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/21/23 indicated the resident was able to express her ideas and wants without difficulties. A review of Resident 25's hearing assessment documented in 'Initial admission Record' dated 11/15/23, indicated that the resident had hearing aids. A review of Resident 25's physician order dated 11/15/23 indicated the following: Monitor hearing aid(s) to left and right ears, every shift .Apply .hearing aids; to left 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that two of 16 sampled residents (Resident 36 and Resident 462) who were dependent on staff for maintaining activities of daily living (ADLs, activities done every day such as eating, personal hygiene, bathing, dressing, and toileting), received the necessary services to maintain good nail care. These failures had the potential to negatively impact Resident 36's psychosocial well-being and had the potential for Resident 36 and Resident 462 to acquire self-inflicted skin injuries due to long fingernails. Findings: 1. A review of the admission Record indicated the facility readmitted Resident 36 in 2023 with multiple diagnoses which included rheumatoid arthritis (an inflammatory and disabling disease of the joints) and fibromyalgia (a disorder that causes fatigue, pain, and tenderness throughout the body). A review of the Minimum Data Set (MDS, standardized assessment and care planning tool), dated 12/20/23, indicated Resident 36 was cognitively intact and did not have behaviors of rejection of ADL 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2026-05-07 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    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 an accurate assessment of the Minimum Data Set (MDS- a comprehensive assessment and screening tool) for 1 of 18 sampled residents (Resident 6), when Resident 6's oxygen therapy section was documented inaccurately.This failure had the potential to result in an inaccurate reflection of Resident 6's health status and the risk for confusion in Resident 6's plan of care.Findings:A review of Resident 6's admission RECORD, indicated Resident 6 was admitted to the facility in 2025 with diagnoses which included pleural effusion (a collection of fluid around the lungs).A review of Resident 6's MDS Section O (Special Treatments, Procedures, and Programs- a specific category to document high-intensity care, therapies, and services a resident receives), dated 1/23/26, indicated that Resident 6 was not on oxygen therapy.A review of Resident 6's MDS Section O, dated 4/29/26, indicated that Resident 6 was not on oxygen therapy.Review of Resident 6's Care Plan, initiated on 11/13/25, indicated, Focus. [Resident 6] had…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.2+0.8 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 4 of 52.7+1.3 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleSince
BUHARI, SHIRAZIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2023
PORT, BARRYIndividualMANAGING CONTROL - GOVERNING BODYsince 07/26/2018
TU, RANDYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2023
WILLITS, ADAMIndividualCORPORATE DIRECTORsince 02/01/2023
BURNAM, SOONIndividualCORPORATE OFFICERsince 11/08/2022
KEETCH, CHADIndividualCORPORATE OFFICERsince 03/01/2011
MONETTE, CORYIndividualCORPORATE OFFICERsince 02/01/2023
SATO, AMIIndividualCORPORATE OFFICERsince 09/09/2024
ENSIGN SERVICES INCOrganizationADP OF THE SNFsince 10/31/2025

CMS files one row per role, so the 13 rows in the source record cover these 9 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.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

$10.8M
Net patient revenuemost recent cost report
+10.6%
Operating marginrevenue minus expenses
$985K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 43%Medicare 41%Other / private 15%

This home reported $985K paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$531per resident / day
operating cost
$16,138per month
≈ monthly operating cost
$594per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055242. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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