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Loma Linda Post Acute

25383 Cole Street, Loma Linda, CA 92354 · For profit - Limited Liability company · 83 certified beds · (909) 796-0235 Medicare & Medicaid certified

Call the home — (909) 796-0235 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Jun 2026
Insights

This home has serious findings on its record. Read them closely before you consider it.

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
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Jun 2026
  • 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
  • its payroll-based staffing rating is low (2/5)

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) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
11201 Benton St · (909) 825-7084 · Call to confirm hours
Pharmacy
11201 Benton St · (909) 825-7084 · Call to confirm hours
Grocery
25630 Barton Rd · (909) 478-5488 · Call to confirm hours
Park
Mountain View Ave · (909) 799-2800 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

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

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.7%10.2%15.4%typical
Long-stay residents who lose too much weight11.2%4.0%5.4%worse
Long-stay residents with a catheter left in their bladder1.4%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms13.2%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 injury0.4%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened9.3%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.7%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers8.4%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control9.3%10.2%21.2%typical for the state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table1.4%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.6%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine99.3%93.2%79.4%better
Short-stay residents rehospitalized after admission23.0%23.0%22.6%typical
Short-stay residents with an outpatient ER visit10.1%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days2.522.251.67worse
Long-stay outpatient ER visits per 1,000 resident days0.731.571.80better

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.

45.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 118 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.9%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
53.5%U.S. median 56.6%
Met the expected recovery
0.52U.S. median 0.31
Therapy hours / resident / day
0.32hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 53.5% 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 101 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 0.52 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.9%CMS range 34.6–53.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 8.6–14.110.7%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 discharge53.5%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 discharge59.4%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 discharge41.6%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 setting98.9%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 discharge93.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.6%CMS range 5.5–14.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.441.02Oct 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

0.48
RN hours/ resident / day
1.11
LPN hours/ resident / day
2.64
Aide hours/ resident / day
4.24
Total nurse hours/ resident / day
0.40
RN hoursweekends
46.4%
Total nursing turnover
70.0%
RN turnover

How full it usually is: this home is certified for 83 beds and averages 78.4 residents a day — about 94% occupied, or roughly 5 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 4.24 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.64 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 3.82 hrs/resident/day on weekends vs 4.41 on weekdays — 13% thinner on weekends. RN hours go from 0.52 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2025-07-03)
1
at the previous standard inspection (2024-06-20)

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

Inspection deficiencies

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

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 · D2026-06-25 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    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 a resident was protected from financial exploitation (the illegal or improper use of a person's money, property, or assets) for one of three residents (Resident 1) reviewed for allegations of financial abuse when Certified Nursing Assistant 1 (CNA 1) attempted to add Resident 1's debit card to the CNA's Apple Pay account. This failure had the potential to placed Resident 1 at risk for financial loss and misappropriation of personal property.Findings: During a review of Resident 1's admission Record (clinical record containing demographic and admission information), the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included dislocation of the left knee (a knee joint that was forced out of its normal position), fractures of the upper and lower right fibula (breaks in the smaller bone of the lower leg), anxiety (a condition causing excessive worry or fear), and depression (a mood disorder causing…

    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 no plan of correction
  • Potential for harm · Fcited before2025-07-03 · 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 dishwashing equipment and food serving utensils were kept in a sanitary condition when:1. The dish drying racks were found to be unsanitary.2. Three scoops stored in a clean storage drawer were found to have dry food particles sticking on the inside part of the scoops.3. Four (4) bags of wheat tortilla were found in the refrigerator past expiration date of June 25, 2025.These failures had the potential to cause cross-contamination of food prepared in the kitchen which can cause severe illness and even be fatal for the 77 vulnerable residents who resided at the facility.Findings:1. During the dishwasher area inspection on July 1, 2025, at 9:42 AM, the dish drying racks (sanitized dishes are placed on these dish racks to air dry) were observed to have significant amount of black-colored substance build-up, scratches, cracks and corrosions in the interior and exterior walls and on the supporting pillars of the drying racks.During an interview with the Director of Kitchen 1 (DOK 1) on July 1, 2025, at 9:50…

    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 · D2025-07-03 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to update Resident 30's Pre-admission Screening and Resident Review (PASARR - a federally mandated program that requires all individuals seeking admission to a Medicaid-certified nursing facility to be screened to ensure individuals who are identified to have a significant mental illness [SMI], intellectual or developmental disability [I/DD] are not inappropriately placed in skilled nursing facilities for long term care) when Resident 30 did not have his diagnoses of major depressive disorder, and anxiety disorder included in the PASARR assessment used to admit Resident 30 into the skilled nursing facility.This failure had the potential to result in Resident 30 being not accurately assessed regarding the need for supplemental treatment and services to better suite the needs of Resident 30.Findings:During a review of Resident 30's admission Record (contains medical and demographic information), the admission Record, indicated Resident 30 was admitted to…

    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 · D2025-07-03 · tag F0646 — isolated
    Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
    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 notify the State Mental Health authority or the State Intellectual Disability authority of a resident's new mental illness diagnosis, when on December 3, 2024, Resident 31 was newly diagnosed with Paranoid Schizophrenia ( a mental disorder that affects a person's ability to think, feel, and behave clearly).This failure had the potential to prevent Resident 31 to receive specialized care and services.Findings:A review of the face sheet (contains demographic information) reveals that Resident 31 was admitted to the facility on [DATE], with diagnoses which include bipolar disorder (a mental health condition characterized by significant and persistent shifts in mood, energy, and activity levels), unspecified dementia (a group of conditions that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment ) with other behavioral disturbance, and post-traumatic stress disorder (a mental health condition…

    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 before2025-07-03 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure physical therapy services were provided to one of two residents (Resident 35) sampled for rehabilitative and restorative services when Resident 35 did not receive physical therapy four times a week as ordered by the physician.This failure had the potential to contribute to a delay in Resident 35's ability to reach his highest level of physical functioning.Findings:During a concurrent observation and interview on June 30, 2025, at 1:08 PM, Resident 35 was lying in bed. When asked how his physical therapy was going, Resident 35 stated he did not think he was receiving physical therapy as often as he was supposed to.During a review of Resident 35's Physical Therapy Medicare PT [physical therapy] Evaluation & Plan of Treatment (outlines resident current level of functioning, diagnoses, goals and physical therapy treatment plan), dated May 19, 2025, the plan indicated Resident 35's start of care date was May 19, 2025, and Resident 35 had diagnoses which included end stage renal disease (the final,…

    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 · D2025-07-03 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided nutritional services to one of one sampled residents (Resident 49) reviewed for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys no longer function) when Resident 49 was not provided a sack lunch on multiple days in May 2025, and June 2025.This failure had the potential for Resident 49 to experience undesirable weight loss.Findings:During a review of Resident 49's admission Record (contains medical and demographic information), the admission Record, indicated Resident 49 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease (a condition where the kidneys are damaged and can't filter blood as well as they should), dependence on renal dialysis (the state where an individual's kidneys have permanently failed and they require regular dialysis treatments to sustain life), anemia in chronic kidney disease (condition in which the body does…

    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 · D2025-07-03 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nursing staff provide a complete pain assessment when a Licensed Vocational Nurse 3 (LVN 3) and a Registered Nurse Supervisor 1 (RNS 1) were observed not performing a complete pain assessment during an emergency for Resident 278 who was experiencing chest pain.This failure had the potential to cause Resident 278 to experience a decline in health status and function.Findings:A record review of Resident 278's Face Sheet (a document which contains basic information about the resident) indicated Resident 278 was admitted to the facility on [DATE], with diagnoses which included presence of prosthetic heart valve (an artificial valve implanted to replace a damaged or diseased heart valve), paroxysmal atrial fibrillation (a condition where the upper chambers of the heart beat irregularly and rapidly), and hypertension (high blood pressure).During an observation On July 2, 2025, at 5:28 AM, A certified nursing assistant informed licensed…

    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 · D2025-07-03 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided assessment and monitoring for one of one sampled residents (Resident 49) reviewed for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys no longer function) when there was no documented evidence staff assessed Resident 49's dialysis access site (the location where a dialysis machine is connected to a patient) after Resident 49 dialysis procedure on June 14, 2025, and June 17, 2025. This failure had the potential for a delay in the staff identification and subsequent treatment of possible dialysis associated complications such as symptoms of infection, bleeding or dislodgement of the dialysis access site for Resident 49. Findings:During a review of Resident 49's admission Record (contains medical and demographic information), the admission Record, indicated Resident 49 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease (a condition…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-03 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals stored in the facility were not expired when on July 2, 2025, three over-the-counter bottles of medications were found to be stored in the medication storage room past their expiration date. This failure had the potential for the expired medications to be accessed and administered to a vulnerable population of 77 residents, potentially resulting in altered effectiveness of the medication and worsening of the residents' symptoms, requiring medical intervention.Findings:On July 2, 2025, at 7:21 AM during the inspection of the medication storage room, three over the counter bottles of expired medications were found stored in a medication cabinet: Simethicone ( a medication used for gas) expired January 2025, Vitamin A - expired June 2024, and Vitamin B complex - expired September 2024.During an interview with the Registered Nurse Supervisor (RNS) on July 2, 2025, at 7:25 AM, the RNS acknowledged that the Simethicone, Vitamin A, and Vitamin B complex medications were expired and…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-29 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents for one of three sampled residents (Resident1). When Resident 1 fell out of bed. This failure contributed to Resident 1 being sent out to acute hospital for evaluation. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: pulmonary edema (excess fluid in lungs), abnormalities of gait and mobility, hypertension (high blood pressure), acute and chronic respiratory failure (lungs cannot exchange oxygen properly), colon cancer (cancer in rectum). During a concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing (DON) reviewed and verified the following: 1. Fall risk assessment on admission March 28, 3025, High Risk=18. 2. Careplan: Falls: Resident is at risk for falls with or without injury related to…

    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
Show the remaining 19 citations
  • Potential for harm · Dcited before2024-06-20 · tag F0640 — isolated
    Encode 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

    Based on interview, record review, document review, and facility policy review, the facility failed to complete and transmit a discharge Minimum Data Set (MDS) for 1 (Resident #22) 1 sampled residents reviewed for resident assessment. Findings included: A facility policy titled, Resident Assessments, revised in 03/2022, indicated, A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments - conducted for all residents in the facility: (1) admission Assessment; (2) Quarterly Assessment; (3) Annual Assessment; (4) Significant Change in Status Assessment; (5) Significant Correction to Prior Comprehensive Assessment; (6) Significant Correction to Prior Quarterly Assessment; and (7) (7) Discharge Assessment. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument…

    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 before2024-06-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 interview and record review, the facility failed to report a possible overdose of narcotics for one of three sampled residents (Resident 1) per the facility policy of within 24 hours to the state agency. This failure had the potential for the possible overdose of narcotics to go uninvestigated and unreported thereby increasing the chances of potential harm to (Resident 1). Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: chronic respiratory failure (lungs cannot get enough oxygen), end stage renal disease (loss of kidney function), type 2 diabetes (condition affecting how body processes sugar), renal dialysis (treatment to filter blood), post-traumatic stress disorder (disorder in which a person has difficulty recovering for experiencing or witnessing a terrifying event). During a review concurrent interview and record review of Resident 1's Medical Record with 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 · Dcited before2023-12-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 interview, and record review, the facility failed to follow the physician ' s order for blood glucose level (the amount of sugar in the blood) monitoring for one of three sampled diabetic (residents with diagnosis of diabetes mellitus [DM- a health condition that affects how your body turns food into energy]) residents (Resident 1). This failure had the potential to cause conditions related to DM such as hypoglycemia (low blood sugar level) and hyperglycemia (high blood sugar level) to remain undetected and cause medical complications. Findings: A review of Resident 1 ' s admission Record (AR), dated December 12, 2023, indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of diabetes mellitus among others. During an interview on December 12, 2023, at 10:06 AM with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 has an order for Insulin Glargine (a long-acting insulin [a medication used to lower blood sugar]) and blood sugar monitoring prior to insulin…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-07 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from injury when the Certified Nurse Assistant 1 (CNA 1) was assisting Resident 1 from a standing position and held Resident 1 with one hand, while reaching for the wheelchair with the other hand during transfer from bed to wheelchair. Resident 1's knees lost postural stability while standing. This failure resulted in Resident 1 falling and sustaining a fractured pelvis (hip bone). Findings: During an interview of on December 7, 2023, at 1:35 PM with Resident 1, Resident 1 stated she had a fall incident, but was unable to give details about it. During a review of Resident 1's admission Record (AR) , dated December 7, 2023, the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included senile (poor mental ability because of old age) degeneration of brain and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-03 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow Policy on reporting when one of three sampled Resident's (Resident 1) eloped from facility. This failure had the potential to cause serious health and psychosocial harm to a clinically compromised Resident (Resident 1). Findings: During review of resident 1s admission Record (General demographics) on ., indicates admitted to facility on June 23, 2023, with diagnosis (DX) of Primary Osteoarthritis (caused by the breakdown of cartilage, a rubbery material that eases the friction in your joints), Diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), Rheumatoid Arthritis (the body's immune system attacks its own tissue, including joints. In severe cases, it attacks internal organs) Gout (occurs when urate crystals accumulate in your joint, causing the inflammation and intense pain) and Edema (occurs when tiny blood vessels in the body, also known as capillaries, leak fluid). During concurrent interview on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-01-10 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews the facility failed to follow the menu when: 1.The incorrect portion of the alternate starch was served to seven residents on a renal (special diet for those with kidney failure) diet and three residents who preferred mashed potatoes instead of rice. They were served with a #12 scoop (2.8 ounces) but should have been served with a #8 scoop (4 ounces), for lunch on January 3, 2023. 2.The cook used a slotted spoon (large plastic or metal spoon with holes in it) instead of a standardized portion server or scoop (Level scoops, ladles, and portion servers provide more accurate portion control than serving spoons that are not volume-standardized measure) to portion the ground meatballs and vegetables (zucchini) according to the Daily Spreadsheet (document that indicates what foods are being served and how much to serve). The 23 residents on a mechanical soft diet (foods are chopped for residents who have difficulty chewing or swallowing) did not receive the correct portion of the meatball as indicated on the Daily spreadsheet. 67…

    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 before2023-01-10 · 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 observations, interviews, and record reviews, the facility failed to maintain professional standards for food service safety when: 1.The walk-in freezer floor had food crumbs and trash under the shelves and under the crates that were storing food. This had the potential for microorganism growth that could be inadvertently transferred to food and may also provide an environment for attraction of pests. 2.The microwave had yellow food crumbs and build-up on the inside, this had the potential to contaminate food heated in the microwave. 3.The stainless-steel wall behind the food preparation area, where the microwave was, had yellow food stains on the wall. This had the potential to attract pests and for microorganism growth that could be inadvertently transferred to food. 4.The floor under the convection oven had black grime, food crumbs and trash. This had the potential for microorganism growth that could be inadvertently transferred to food and may also provide an environment for attraction of pests. 5.There was food crumbs, black grime and trash build-up under the stove…

    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 · E2023-01-10 · tag F0641 — pattern
    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 interview and record review the facility failed to accurately reflect the resident's status in the Minimum Data Set (MDS - computerized resident assessment completed by a licensed nurse) Assessments for 12 sampled residents when: 1. The facility did not complete MDS Discharge Assessments for 11 residents (Residents 79, 88, 84, 89, 58, 85, 6, 42, 87, 86, and 77) who were reviewed for MDS data completion. 2. The facility did not accurately code Section N: Medications of the MDS for antibiotics (medication given to treat bacterial infections) for Resident 83. This failure to notify the oversight agency (Centers for Medicare and Medicaid Services - CMS) who provides funding for residents has the potential for monies to continue to be paid to the facility after a resident has been discharged , and for services not rendered to the resident. Findings: 1. During a review of the facility's MDS assessments on January 5, 2023, at 2:15 PM, 11 residents (Residents 79, 88, 84, 89, 58, 85, 6, 42, 87, 86, and 77) did…

    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 · Ecited before2023-01-10 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to properly store medications when: 1. One bottle of liquid oral Pantoprazole (a medication given to reduce acidity in the stomach and esophagus) was left unsupervised on top of a medication cart and was accessible to others. This failure had to potential to allow medication access to residents, staff, and others passing by who do not have the authority to handle medications. 2. One bottle of liquid oral Gabapentin (a medication given for nerve pain) which required refrigeration was found stored in the bottom drawer of a medication cart. This failure had the potential to negatively affect the medication's effectiveness when administered. 3. Six Insulin Pens (a pen-like device used to inject insulin - a medication given via injection to control blood sugar levels) were found without proper labeling, for four residents (Resident 2, 15, 34, and 41). This failure had the potential to improperly identify the opening and expiration date of the insulin. Findings: 1 .During an observation on January 5, 2023, at 7:17 AM,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-10 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 staff discussed with two residents (Residents 12 and 164) upon admission whether or not they had an existing advanced directive (a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions) or wanted to establish a new advance directive. This failure had the potential for both Residents 12 and 164 to receive end of life care not in accordance with their wishes and for life sustaining measures to be rendered against what the residents wanted. Findings: a. During a review of Resident 12's medical record, the admission Record (contains medical and demographic information), indicated Resident 12 was admitted on [DATE], with diagnoses which included end stage renal disease (kidney failure), acute (happens quickly and without much warning) respiratory failure, and type 2 diabetes mellitus (a disease which impairs the body's ability to regulate blood sugar). During a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-10 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 a Minimum Data Set (MDS) (a computerized clinical assessment) Significant Change Assessment (SCA) within 14 days for two sampled residents (Resident 93 and 83), who were reviewed for hospice (a program providing services for the care of terminally ill residents and their family) services as evidenced by: 1.The facility did not complete a MDS SCA for Resident 93 within 14 days of admission to hospice services. 2.The facility did not complete a MDS SCA for Resident 83 within 14 days of discharge from hospice services. This failure had the potential to delay identification and implementation of necessary interventions to address the resident's care and support needs. Findings: 1. During a review of Resident 93's clinical record, the record indicated the resident was admitted to the facility on [DATE]. The record further indicated the resident was admitted to hospice services on November 8, 2022, with diagnoses which included malignant neoplasm 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-10 · tag F0640 — isolated
    Encode 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

    Based on interview and record review, the facility failed to electronically submit two Minimum Data Set (MDS - a computerized assessment completed by a licensed nurse) Assessments within 14 days of completion, for two residents (Residents 90 and 55) who were reviewed for MDS data completion. This failure to notify the oversight agency (Centers for Medicare and Medicaid Services - CMS) who provides funding for residents has the potential for monies to continue to be paid to the facility after a resident has been discharged . Findings: During a review of the facility's MDS electronic submission of assessments on January 5, 2023, at 2:15 PM, two MDS assessments, for Resident 90 and 55, were found to have been completed, but not submitted to CMS. Resident 90 was discharged from the facility on November 15, 2022, but as of January 5, 2023, the discharge MDS assessment had not yet been electronically submitted to CMS. Upon further review, Resident 55 was discharged from the facility on October 31, 2022, but as of January 5, 2023, the discharge MDS assessment had not yet been…

    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 · D2023-01-10 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for five sampled residents (Resident 36, 93, 41, 83, and 12) when: 1.The facility did not develop a comprehensive care plan for pain, for Resident 36. 2.The facility did not develop a comprehensive care plan for hospice for Residents 36, 93, 41, and 83 within seven days of a comprehensive Minimum Data Set (MDS - a computerized resident assessment) Assessment. 3.The facility did not develop a comprehensive care plan for dialysis (a process of filtering out the blood through a machine, when the kidneys are unable to do it by themselves), for Resident 12. These failures had the potential to prevent the resident's medical, physical well-being, and psychosocial needs from being met. Findings: 1.During a review of Resident 36's clinical record, the admission Record (contains demographic information) indicated the resident was admitted to the facility on [DATE], with diagnoses which included chronic osteomyelitis…

    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 before2023-01-10 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide evidence that one resident (Resident 164) was provided assistance with a shower or bath in accordance with the shower schedule and policy and procedure when the resident stated he had not had a shower for 20 days from the date he was admitted into the facility (December 14th, 2022) to the date of interview on January 3, 2023. This failure had the potential to result in resident 164 to have poor personal hygiene and cleanliness and experience a decline in his functional ability to maintain performance of activities of daily living (ADLs - i.e. bathing, grooming etc). Findings: A review of Resident 164's clinical record, the admission Record (contains medical and demographic information), indicated Resident 164 was admitted to the facility on [DATE], with diagnoses which included unspecified injury at unspecified level of cervical spinal cord (neck injury), spondylosis (slow degeneration of the spine) with myelopathy (spinal cord…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide evidence wound care was provided to one resident (Resident 165) as ordered by the physician for the month of December 2022 when: a. Resident 165's clinical record did not indicate treatment was provided for six out of 21 days for the treatment of the resident's coccyx (tailbone) region for a stage two pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin. In stage two, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) between December 8, 2022, and December 28, 2022. b. Resident 165's clinical record did not indicate treatment was provided for six out of 14 days for the treatment of redness to the residents left great toe between December 8, 2022, through December 21, 2022. c. Resident 165's clinical record did not indicate treatment was provided for three of 18 shifts for treatment of redness to the residents left and right buttocks between January 2, 2022,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a Right Ankle Foot Orthosis (AFO - device to correct alignment or provide support for weak muscles of the ankle and foot) Brace as ordered by the physician for Resident 91. This finding had the potential to impede the resident's rehabilitation success due to necessary devices not being available for foot mobility management and comfortability. Findings: During a review of Resident 91's clinical record, the admission Record (contains demographic information) indicated the resident was admitted on [DATE], with diagnoses which included right sided hemiplegia (paralysis of all or partial body function on one side) following a cerebral infarction (disruption of blood flow to the brain), liver cirrhosis (scarring of the liver caused by long-term liver damage), and muscle weakness. Further review of the record indicated a physician's order was placed on November 18, 2022, for (R) [right] AFO for (R) [right] foot drop mgt [management] .…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-10 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff followed facility policy for flushing (to clear by using a prescribed amount of water) G-tube (gastrostomy tube-a tube inserted through the abdominal wall that brings liquid nutrition or medications directly to the stomach) in-between medication administration for one Resident (Resident 14). This failure had the potential to cause an interaction between medications resulting in a reduced drug effect, or drug toxicity, as well as clogging the G-tube. Findings: A review of Resident 14's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 14 was admitted to the facility on [DATE], with a diagnosis of sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood), pulmonary hypertension (A type of high blood pressure that affects arteries in the lungs and in the heart) and dysphagia (Difficulty swallowing foods or liquids) following…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-10 · tag F0885 — failed to notify residents/families about COVID-19 — isolated
    Report COVID19 data to residents and families.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to inform resident representatives and families of identified positive COVID-19 (an illness caused by a virus) cases by five PM the following day. This had the potential for resident representatives and families to not be informed of current positive cases occurring within the facility of which their family resided. Findings: During an interview on January 10, 2023, at 2:40 PM, with the Infection Preventionist (IP), the IP stated the facility's Administrator (ADMIN) was responsible for notifying resident representatives and families regarding COVID-19 positive cases within the facility. During an interview on January 10, 2023, at 3:21 PM, with the ADMIN, the ADMIN stated the facility did not send out notification to resident representatives and families after every individual COVID-19 positive case identified within the facility's staff and residents. The ADMIN further stated instead, the facility sent out a notification letter or email approximately every month with information regarding the total number of positive COVID-19…

    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
  • No harm found · B2025-07-03 · tag F0577 — pattern
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 post the results of the facility's most recent recertification survey when it was discovered the survey results were not posted anywhere in the facility.This failure resulted in residents and visitors inability to read the survey results and assess facility's compliance with regulations which directly impacts their well-being and quality of life within the skilled nursing facility.Findings:During an observation on July 3, 2025, at 10:40 AM, a binder titled, Survey Results Binder 2022, 2023, 2024 was observed to be posted on the wall in one of the main hallways of the facility. Upon review of the contents of the binder, there was no survey information in the binder for the facility's recertification survey in 2024.During a concurrent observation and interview on July 3, 2025, at 10:43 AM, with the Administrator (ADMIN), the ADMIN stated the facility's previous recertification survey results were supposed to be in the survey binder. The ADMIN reviewed the survey binder and stated he did not know why the most…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PACS GROUP — 274 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 52.9+1.1 vs chain
Health inspection 4 of 52.5+1.5 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 273 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Anchor Post AcuteAiken, SC 1 of 5Arbor Post AcuteChico, CA 1 of 5Artesia Palms Care CenterArtesia, CA 1 of 5Arvin Post AcuteArvin, CA 1 of 5Ashland Post AcuteAshland, OR 1 of 5Bakersfield Post AcuteBakersfield, CA 1 of 5Beachwood Post-Acute & RehabSanta Monica, CA 1 of 5Brookshire Post AcuteDenver, CO 1 of 5Brushy Creek Post AcuteGreer, SC 1 of 5Buckeye Care And RehabilitationLancaster, OH 1 of 5Carnegie Park Post AcutePittsburgh, PA 1 of 5Cascade Terrace Post AcutePortland, OR 1 of 5Centennial Post AcuteAnchorage, AK 1 of 5Chandler Creek Post AcuteGreer, SC 1 of 5Chehalem Post AcuteNewberg, OR 1 of 5Country Hills Post AcuteEl Cajon, CA 1 of 5Delhi Post-AcuteCincinnati, OH 1 of 5Dublin Post AcuteDublin, OH 1 of 5Edisto Post AcuteOrangeburg, SC 1 of 5Evan Terrace Post AcuteMcMinnville, OR 1 of 5Forest Acres Post AcuteColumbia, SC 1 of 5Grandview Post AcuteCookeville, TN 1 of 5Great Plains Post AcuteWichita, KS 1 of 5Hemet Hills Post AcuteHemet, CA 1 of 5Highland Hills Post AcutePittsburgh, PA 1 of 5Highline Post AcuteDenver, CO 1 of 5Johns Island Post AcuteJohns Island, SC 1 of 5Karcher Post AcuteNampa, ID 1 of 5Kennedy Care CenterLos Angeles, CA 1 of 5Kern River Transitional CareBakersfield, CA 1 of 5Lakeview Post AcuteFlorissant, MO 1 of 5Marion Valley Post AcuteMarion, OH 1 of 5Mirage Post AcuteLancaster, CA 1 of 5Monroeville Post AcuteMonroeville, PA 1 of 5Napa Post AcuteNapa, CA 1 of 5North Royalton Post AcuteParma, OH 1 of 5Northstar Post AcuteCarson City, NV 1 of 5Overland Park Post AcuteOverland Park, KS 1 of 5Pikes Peak Post AcuteColorado Springs, CO 1 of 5Ridgeway Post AcutePetaluma, CA

Showing 40 of 273; 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 / managerTypeRoleShareSince
LOMA LINDA MASTER TENANT LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/24/2023
PROVIDENCE GROUP NH, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 06/30/2023
TRUIST BANKOrganization5% OR GREATER SECURITY INTERESTsince 12/07/2023
APT, FREDERICKIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
DIMAUNAHAN, JOELIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/09/2024
JARDINE, KENNETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2024
JERGENSEN, JOSHUAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
LORDS, TREVORIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2025
MITCHELL, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
PAI, SHANTHARAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/02/2025
PROVIDENCE ADMINISTRATIVE CONSULTING SERVICES INCOrganizationADP OF THE SNFsince 06/30/2023

CMS files one row per role, so the 14 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$6.8M
Net patient revenuemost recent cost report
+9.5%
Operating marginrevenue minus expenses
$355K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 8%Medicare 15%Other / private 77%

This home reported $355K 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

$417per resident / day
operating cost
$12,688per month
≈ monthly operating cost
$461per 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 055299. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-03, 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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