Lompoc Skilled Nursing & Rehabilitation Center
1428 West North Avenue, Lompoc, CA 93436 · For profit - Limited Liability company · 120 certified beds · (805) 735-4010 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- 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
- the CMS record shows $4,893 in federal fines (most recent 2023-09-18)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 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 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.5% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.1% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.8% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 3.2% | 1.2% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 2.4% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.1% | 1.6% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 6.4% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.5% | 13.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 99.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.8% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 5.7% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.9% | 12.0% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 95.4% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.7% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 19.0% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.25 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.22 | 1.57 | 1.80 | worse |
‡ 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.
58.0% 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 324 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 143 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 0.53 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.0%CMS range 53.0–61.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 7.6–12.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 58.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 47.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 46.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 81.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 4.6–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.19 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 89.3 residents a day — about 74% occupied, or roughly 31 beds typically open. It usually has some room. 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 4.11 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.70 hrs/resident/day on weekends vs 4.28 on weekdays — 13% thinner on weekends. RN hours go from 0.60 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
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 · Dcited before2025-06-23 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its facility policy to re-weigh residents with a five percent (5%) or greater weight loss and immediately notify the Registered Dietician (RD) in writing for one (1) of three (3) sampled residents (Resident 1). This failure resulted in Resident 1's increased weight loss, worsening malnutrition (not getting enough healthy food or nutrients), delayed medical treatment, and adverse consequences as evidenced by slower healing of pressure sores. Findings: Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 243 in the section titled, Data Documentation indicates, Observation and recording of client status is a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Nursing's Social Policy Statement (2003) mandate, or require, accurate data collection and recording as independent functions essential to the role of the professional nurse. During a review of Resident 1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure standard and transmission-based precautions were followed to prevent the spread of infections when: 1. A Foley catheter bag (urine collection bag) was not touching the floor in one of three residents (Resident 1). 2. Staff didn't follow handwashing protocol per infection control standards to provide hand hygiene to one of three sampled residents (Resident 1) and one unsampled resident (Resident 2) before serving lunch meal trays. These facility failures had the potential to transmit and spread infection to residents, visitors, and staff. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur (a break in the bone between the hip and thigh bone), acute kidney failure (decline kidney function), pressure ulcers on right and left buttock and on the sacral region (injuries to the skin and underlying…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-21 · tag F0554 — isolatedAllow 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 one of five sampled residents, (Resident 62), self-administration of medication was with interdisciplinary team (IDT- healthcare professionals from different specialties working together to provide patient care) approval and determination as clinically safe and appropriate. This failure had the potential for Resident 62 to unsafely self-administer medication. Findings: During a concurrent observation and interview on 2/19/25 at 9:47 a.m., with Resident 62, a rescue inhaler labeled Atrovent HFA (medication that relaxes muscles in the airways, 17 mcg (microgram -unit of measure) was observed inside Resident 62's bedside table drawer. Resident 62 stated the inhaler was brought from home to use as a back-up when going outside the facility to smoke. During an interview on 2/19/25 at 9:48 a.m. with Licensed Nurse (LN2), LN2 stated not being aware of the presence of the inhaler in Resident 62's drawer. LN 2 further stated Resident 62 did not have approval from the physician and the IDT team to self-administer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-21 · tag F0577 — isolatedAllow 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 have the most current survey results accessible to the public, in the facility survey results binder. This facility failure denied the opportunity for residents, family members, and legal representatives of residents, to be aware of the most recent survey results. Findings: During a concurrent observation and interview on 2/18/25, with the Administrator (ADM) inside the facility's main entrance, the facility's survey results binder was reviewed. The most current survey results in the binder were from 3/15/24. The survey results binder lacked the survey results from 4/8/24 through 1/30/25. The ADM acknowledged the survey results binder was not current and verbalized the survey results binder would need to be updated. During a review of the facility's policy and procedure tilted Survey Results, Examination of dated 4/7, indicated in part A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state approved plans of correction of noted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow care plan (a document that summarizes how a patient's needs will be met, and their care will be managed) interventions for call lights, for two of 23 sampled residents (Resident 17 and Resident 44) when: 1. Resident 44's call light was out of reach, on the floor. 2. Resident 17's call light was out of reach. These failures had the potential for Resident 44 and Resident 17's needs to go unmet by staff. Findings: 1. During an observation on 2/19/25 at 10:06 a.m. Resident 44's call light was observed on the floor and out of reach of Resident 44. During a concurrent observation and interview on 2/19/25 at 10:22 a.m. with Certified Nursing Assistant (CNA 2), CNA 2 confirmed and verbalized Resident 44's call light was on the floor and out of reach of Resident 44. During a review of Resident 44's Care Plan Report undated, indicated in part, Resident 44 was at risk for falls with an approach to Ensure call light is within reach and encourage the resident to use it for assistance as needed. 2. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-21 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow physician orders for three of 23 sampled residents (Resident 93, Resident 32, and Resident 12) when the facility staff did not: 1. Check Resident 93's blood pressure prior to the administration of hydralazine (a medication used to treat blood pressure). This failure had the potential for Resident 93 to receive Hydralazine, against physician orders, secondary to no monitoring. 2. Weigh Resident 32 per physician orders. This failure had the potential to adversely affect Resident 32's heart condition. 3. Check Resident 12's blood pressure prior to the administration of Lisinopril (a medication used to treat blood pressure). This failure had the potential for Resident 12 to receive Lisinopril, without following the precautionary parameters ordered by the physician. Findings: Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicates, Nurses are obligated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-21 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure emergency drugs were available to residents when ordered. The facilities Emergency Drug Supply Kit (E-Kit) was not re-ordered timely after being opened for use. This failure had the potential for emergency drugs to not be available during an emergency. Findings: During a concurrent observation and interview on 2/19/25 at 1:27 p.m., with the Director of Staff Development (DSD) in the medication storage room, one opened E-Kit was observed in the refrigerator room with red locks. The DSD stated a red lock indicates an E-Kit has been opened by facility staff, and the nurse who opened it should have reordered it that same day. During an interview on 2/21/25 at 1:58 p.m., with the Director of Staff Development (DSD), the DSD stated the last time the E-Kit was ordered was in August 2024. There was no other documented evidence that the refrigerator E-kit was reordered from the time it was opened to 2/19/25. During a review of the facility's Policy and Procedure titled, Emergency Medications, dated April 2021, the P&P…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-21 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications were administered as directed and ordered when: 1. Resident 72 was not given /administered with Insulin (a medication to lower blood sugar levels) when the resident's blood sugar level /reading went above the parameter set by the physician. 2. Resident 42 was not administred with Diltiazem (medication for high blood pressure )when the resident's blood pressure level was above the parameter set by the physician. These failures had the potential medication errors secondary to non administration as ordered. Findings: 1. During review of Resident 72's admission Record (AD), the AD indicated Resident 72 was admitted on [DATE] with diagnoses that include non-pressure chronic pressure ulcer of left heel and midfoot (a persistent, open sore located on the left heel and middle part of the foot that develops due to underlying conditions like poor circulation or diabetes), type 1 diabetes mellitus with ketoacidosis (a life-threatening…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-21 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. Six opened nebulizer (turns medicine into a mist) medications were labeled with opened dates for two sampled residents (Resident 11 and Resident 94) and three unsampled residents (Resident 43, Resident 103, and Resident 463) per facility policy. 2. Three expired test strips in one medication cart were discarded and not readily available for staff use. These failures had the potential for residents to receive expired and ineffective medications. Findings: 1. a. During a concurrent observation and interview on [DATE] at 2:14 p.m., with the Director of Staff Development (DSD) in the nurses' station, the following liquid inhalation medication solution packets were observed to be unlabeled and undated: D1 Medication Cart One Albuterol packet for Resident 463. One DuoNeb packet for Resident 463. Three Budesonide packets for Resident 103. A1 Medication Cart Two Budesonide packets for Resident 43. One DuoNeb packet for Resident 11. C2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-21 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medical records for three out of 23 residents (Resident 17, 37, 94) accurately documented POLST (Physician Orders for Life-Sustaining Treatment (gives instructions for care in life-threatening medical situations) information in the electronic medical record (EMR) when: 1. Resident 94's POLST did not match the electronic health record. 2. Resident 37's POLST did not match the electronic health record. 3. Resident 17's POLST did not match the electronic health record. These failures had the potential to result in Residents 17, 37, and 94 not receiving their desired preferences for end of life care. 1. During a review of Resident 's admission Record (AR), the AR indicated, Resident 94 is a [AGE] year-old female admitted on [DATE] with diagnosis of chronic respiratory failure with hypercapnia (inadequate breathing) and COPD (chronic obstructive pulmonary disease - lung condition caused by inflammation that limits airflow into and out 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.
Show the remaining 19 citations
- Potential for harm · Dcited before2025-02-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain infection control practices when: 1. Respiratory care equipment was not stored in a manner to prevent cross contamination (accidently transferring harmful bacteria) for one of five sampled residents (Resident 62). 2. Nasal cannula tubing (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not labeled and dated for three of six sampled residents (Resident 12, Resident 70 and Resident 89). These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare Associated Infections) for residents in an already compromised condition. Findings: 1. During review of Resident 62's admission Record (AD), the AD indicated Resident 62 was admitted on [DATE] with diagnoses that include hypertensive heart disease with heart failure (high blood pressure that causes blood 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.
- Potential for harm · Dcited before2024-12-06 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to ensure 1 of three sampled residents (Resident 1), urine outputs via Foley catheter (thin, flexible tube that drains urine from the bladder into a bag outside the body) were not accurately documented. This failure may have contributed to the hospital transfer to the emergency room for Resident 1. Findings During an interview on 11/19/24 at 11:41 a.m. with Resident 1 (RS1), stated, I was having some pain regarding the catheter, and then I went to the ER [Emergency Room] and the ER pulled the catheter, and then a bunch of urine came out and the pain was relieved . The day I went to the ER there seemed to be a disconnect with the staff, one staff was telling me to drink more water, and another was telling me to stop playing with the catheter . During an interview on 11/21/24 at 12:36 p.m. with Director of Staff Development (DSD), DSD wrote via email, .it looks like the task for the catheter output was not initiated until 11/7/24. That has to be done for it to trigger on PCC [Point Click Care, electronic charting system] for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure physician orders for Lactulose (a medication that helps prevent complications of liver disease and relieves constipation) were adhered to, for one of two sampled residents (Resident 1) when: 1. Resident 1 did not receive a scheduled dose of Lactulose due to a family outing. 2. Nursing staff did not notify Resident 1's physician, when Resident 1 had less than three bowel movements a day, on four separate occasions. This failure placed Resident 1 at risk to have irregular bowel moements and other adverse reactions. Findings: 1.During a concurrent interview and record review, on 10/3/23, starting at 12:57 p.m., with the Assistant Director of Nursing (ADON 1), Resident 1's Medication Administration Record (MAR) was reviewed. Resident 1's MAR indicated on 10/9/22, an active order for Lactulose Solution 10 GM (grams)/15 ML (milliliters) Give 30 ml by mouth three times a day for Alcoholic liver cirrhosis (a condition where a person's liver is scarred and permanently damaged). Resident 1's MAR indicated on 10/9/22, at 1:00…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-03 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review and, the facility failed to ensure staff accurately assessed and documented a fall risk evaluation for one of two residents (Residents 1). This failure had the potential to result in Resident 1 not receiving appropriate interventions for falls. Findings: During a review of Resident 1's admission Record, dated 5/26/23, this indicated Resident 1 had a history of falling. During a review of the record titled,SBAR Communication Form dated 8/15/23, this record indicated Resident 1 was observed in a seated position on the floor near the foot of the bed. During a review of the record titled,NSG: Fall Risk Evaluation dated 8/15/23, this indicated Resident 1 was high risk for falls with a care plan and interventions. During a review of the record titled,SBAR Communication Form dated 8/20/23, this record indicated Resident 1 had a fall and was sent to the hospital for further evaluation and treatment. During a review of the record titled,NSG: Fall Risk Evaluation dated 8/20/23, this indicated Resident 1 was at moderate risk for falls with a care plan and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-18 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to properly implement infection prevention and control practices according to recognized guidelines when: 1. Personal protective equipment (PPE - gowns, gloves, masks, and face/eye protection to protect body from injury or infection) supplies required during contact with residents placed on Enhanced Standard/Barrier Precautions [ESBP - an infection control intervention to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes and involve gown and glove use during high-contact resident care activities] were placed inside the room in close proximity to the residents. 2. A certified nursing assistant (CNA 3) was observed changing bed linen in a resident's room placed on ESBP without appropriate PPE. 3. An environmental services staff (ESS 1) failed to verbalize correct concentration of the diluted bleach solution used to cleanse and disinfect the floor in resident care areas. These failures had the potential to result in cross-contamination, spread of infectious agents, and ineffective…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-18 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote Resident 95's dignity when Resident 95 received assistance with eating, in the dining room in the Alzheimer's unit, 45 minutes before a resident at the same table received his meal, and while six other residents in the small dining room waited for their lunch meal. In addition, Resident 40 was not provided dining in a dignified manner when Resident 40 received assistance with eating in a hallway, while multiple other residents in the same hallway continued to wait 45 minutes for their lunch meal. Findings: During an observation on 08/15/23, at 12:35 p.m., in the hallway in front of Resident 40's room, Resident 40 was observed in his wheelchair receiving assistance with eating lunch from Certified Nursing Assistant (CNA) 2. Another resident was observed sitting in a chair in close proximity to Resident 40, while multiple other resident's located in the same hallway waited for their lunch. During a concurrent observation and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-18 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 written informed consent was secured from one of 25 sampled residents (Resident 61) or from the resident's representative, for a dosage increase of the medication Duloxetine [a psychotropic medication (alters mood, perceptions, and behavior) used to treat depression and anxiety]. This failure violated Resident 61's right to be informed of a change in psychotropic medication regimen. Findings: During a review of Resident 61's admission Record (AR), dated 3/9/22, the AR indicated in part, Resident 61 was a [AGE] year-old, female resident, who was initially admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (paralysis of one side of the body), unspecified insomnia (sleeplessness), and unspecified anxiety disorder. During a review of Resident 61's Order Summary Report, dated 8/18/23, the report indicated, the physician order, dated 9/8/22, Duloxetine HCl (hydrochloride) capsule delayed release, sprinkle 60 mg…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure an accurate and effective system for monitoring parameters of nutritional status for one of 6 sampled residents (Resident 43), when: 1. A comprehensive nutrition assessment was incomplete when Resident 43's individual daily calorie, protein and fluid needs were not assessed on admission. 2. A gradual, weight loss goal consisting of twenty-four pounds was documented as non-significant weight loss on Resident 43's admission Nutrition Comprehensive Assessment (NCA) and on the interdisciplinary team (IDT) nutrition care plan (IDTNCP) had not involved the physician to ensure the provider responsible for the care of the patient was guiding the nutrition care plan. The NCA and/or IDTNCP lacked documentation to ensure communication of risks/benefits of weight loss for the [AGE] year old resident with dementia occurred with Resident 43's responsible party (RP) to ensure informed decision, when weight loss was not in accordance with standards of practice…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-18 · tag F0801 — isolatedEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 director of food and nutrition services (Dietary Manager] received consistent and sufficient frequently scheduled consultations from the facility's Registered Dietitian (RD) to include overseeing food safety and sanitation, food preparation, meal service and food storage. As a result, there were lapses in the delivery of food and nutrition services associated with safe food handling and sanitation (Cross Reference F812), meal distribution (Cross Reference F550) and implementation of therapeutic diets (Cross Reference F803). Findings: During a concurrent observation and interview on 08/15/23, at 10:06 a.m., with Dietary Aide (DA) 1, in the kitchen, DA 1 was observed using a spray bottle to spray a solution onto a meal delivery cart and proceeded to immediately wipe off the solution with a white terry cloth towel. During an interview on 08/15/23, at 10:09 a.m., with Dietary Manager (DM) and DA 1, DA 1 verified he did spray the sanitizing solution onto the meal delivery cart and immediately wiped off…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-18 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the therapeutic diet/menu as planned during lunch trayline (a system of food preparation in which trays move along an assembly line) when: 1. A salt packet was placed on the lunch meal tray for 2 of 25 sampled residents (Resident 53 and Resident 112) who had a physician prescribed Heart Healthy diet order. 2. The Soft, Bite Sized Food (SB6) diet was not followed related to the size of green beans in accordance with the facility's Diet Manual for SB6 diet, for one of 25 sampled residents (Resident 89). This failure had the potential to negatively impact the residents nutritional and/or medical status. In addition, not following the correct size of food for a SB6 diet had the potential to place the resident at an increased risk of choking. Findings: 1. During a concurrent observation and interview on 08/16/23, at 11:30 a.m., of the lunch trayline meal service in the kitchen, Resident 53's meal tray was observed placed on the meal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-18 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure one of 25 sampled residents (Resident 43) meal tray card that listed dinner roll as a food dislike was honored when a dinner roll was served on Resident 43's lunch meal plate. Failure to follow a resident's food preferences had the potential to result in decreased meal consumption and weight loss. Findings: During a concurrent observation and interview on 08/15/23, at 01:02 p.m., with Certified Nursing Assistant (CNA) 4, in Resident 43's room, CNA 4 observed a dinner roll on Resident 43's lunch meal plate and verified dinner rolls was listed as a food dislike on Resident 43's lunch meal card. CNA 4 stated the dinner roll should not have been served. Resident 43 stated she does not like dinner rolls and when the list of dislikes listed on her meal tray card was reviewed with her, Resident 43 pointed to her dinner roll, and stated, Imagine that. During a review of the facility's planned lunch menu for 8/15/23, the lunch meal included Dinner Roll . During a review of the facility's policy and procedure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-18 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure effective sanitary practices and safe food handling when: 1. One of two food and nutrition services staff was not following manufacturer's guidelines for contact time related to sanitizing meal delivery carts to ensure they were effectively sanitized. 2. Three of five logged entries on the Cooling Temperature Log indicated TCS foods (Time-Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) were not accurately cooled down to ensure food safety. 3. Dry food ingredients were stored directly in non-food grade trash liners. As a result, residents were placed at an increased risk for developing a food borne illness. Findings: 1. During a concurrent observation and interview on 08/15/23, at 10:06 a.m., with Dietary Aide (DA) 1, in the kitchen, DA 1 was observed using a spray bottle to spray a solution onto a meal delivery cart and proceeded to immediately wipe off the solution with a white terry cloth towel. DA 1 was observed three times spraying…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement a care planned intervention, to monitor meal intake percentage, and to offer a meal alternative, if less than 50% of a meal was consumed, for one of two sampled residents (Resident 1). This facility failure had the potential to be a contributing factor in Resident 1's weight loss, while at the facility. Findings: During a concurrent record review and interview on 8/11/23, starting at 9:33 a.m., with the Assistant Director of Nursing (ADON 1) and the Medical Records Assistant (MRA 1), Resident 1's medical record was reviewed. Resident 1's Care Plan indicated in part. At risk for altered nutritional status r/t (related to) inadequate energy intake with an approach/task to Monitor food intake and record every meal. If resident (Resident 1) consumes less that 50% of meal offer alternative. This care planned problem and approach/task was initiated when Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Documentation Survey…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-14 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide documentation indicating multiple physician orders were carried out, for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1's care needs to go unmet. Findings: During a concurrent record review and interview on 8/11/23, starting at 9:33 a.m., with the Assistant Director of Nursing (ADON 1) and the Medical Records Assistant (MRA 1), Resident 1's physician orders were reviewed. Resident 1 had a physician order for staff to monitor for signs and symptoms of infection and changes for a right ankle wound, every shift. On 7/6/23, 7/12/23, and 7/24/23, Resident 1's Medication Administration Record (MAR), dated 7/23, had missing night shift entries. Resident 1 had a physician order for a wound vacuum (a device that decreases air pressure on a wound, to help the wound heal more quickly) dressing change every Monday, Wednesday, and Friday; and to irrigate the wound with normal saline, pat dry with gauze, protect wound margins with adhesive strips and trim vacuum foam to fit/fill…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-10-10 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection prevention and control when: 1. Facility staff failed to perform handwashing before and after wearing gloves during medication pass observation for Resident 505; 2. Expired biological culture vials were found in the medication cart; 3. Facility recorded laundry washer and dryer temperatures without any device such as thermometer; 4. Facility used alcohol swabs to disinfect the blood glucometer for one of 10 sampled residents: 5. Three cartons of milk, and one yogurt were found at room temperature in Resident 26's bedside table. These findings had the potential to develop and transmit communicable diseases and infections to Residents. Findings: 1. During an observation of medication administration with a Licensed Nurse (LN 3), beginning October 8, 2019, at 5:10 AM, LN 3 came out from a resident room [room [ROOM NUMBER]] without hand sanitization using antimicrobial gel, or handwashing. LN 3 was then observed to put on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-10-10 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure professional standards were met for three of 30 sampled residents (Resident 506, Resident 68, and Resident 62) when: 1. Facility Social Services Designee (SSD) failed to record Resident 506 belongings [hearing aids], and was unaware of the presence of hearing aids from Resident 506's admission to death; and 2. Facility Licensed Nurse (LN 5) failed to verify physician orders for two antihypertensive medications (used to treat high blood pressure) with no medication parameters for Resident 68; and 3. Facility Licensed Nurse (LN 4) failed to follow Resident 62's physician order of water hydration through Gastrostomy tube (tube placed in the stomach for nutritional support), when water hydration bag was left almost full for 12 hours. These failures had the potential to result in residents not having belongings kept safely, or sustaining adverse effects from medication or lack of fluids. Findings: 1. During medication cart observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-10-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to label the water hydration bag with the resident name, date and time the bag was hung for one of three sampled resident (Resident 62). This failure has the potential for not correctly administering the correct amount of water that needed to be given to the resident. Findings: During an observation on October 7, 2019, at 8:29 AM, an empty water hydration bag for Resident 62 was observed without a label. During an interview with a Licensed Nurse (LN 8), on October 7, 2019 on 8:33 AM, LN 8 confirmed the water hydration bag needs to be labeled with the name of the resident, the date and time the water hydration bag was hung. During an observation on October 9, 2019, at 8:35 AM, the water hydration bag for Resident 62 was almost full, and was not labeled. During an interview with a Licensed Nurse (LN 1), on October 9, 2019 at 8:40 AM, LN 1 confirmed that the water hydration bag for Resident 62 should be labeled with the name of the resident, and the date it was hung. During a review of the clinical record for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-10-10 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure complete medical records for 1 of 30 sampled residents (Resident 68). This failure had the potential to result in confusion or inaccurate entries into the medical record of Resident 68. Findings: During a review of the clinical record for Resident 68, the Weekly Weights Record had the date and weight recorded, but no identifiable information on whom the record belonged to. During an interview with a Licensed Nurse (LN 6) on October 9, 2019, at 10:33 AM, LN 6 reviewed the record and confirmed that no sufficient identifiable information was on the record and stated, There should be a written resident information on the record or sticker with resident's information. During an interview with the Medical Records Director (MR), on October 9, 2019, at 2:13 PM, the MR stated, All records should have written resident information or a sticker with the resident's identifiable information. The facility policy and procedure titled, RECORD CONTENT, dated 01/04, indicated in part, Identification of Records - Each sheet in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-10 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 antibiotic use protocol for Resident 95 when: 1. The facility had no documented monitoring of clinical signs and symptoms for effectiveness or adverse effects during antibiotic therapy; and 2. The facility used the antibiotic as physician ordered, without documented duration of antibiotic therapy; and 3. Facility did not include Resident 95 in the list of other residents who received antibiotics for the months of September, and October 2019. These findings has the potential for Resident 95 to have development of antibiotic-resistant organisms, and other adverse effects from unnecessary or inappropriate antibiotic use. Findings: During a review of the clinical record for Resident 95, the admission records indicated Resident 95 was admitted to the facility in February 2019, with diagnoses of a urinary tract infection (UTI), and chronic kidney disease. The physician orders dated February 14, 2019, indicated, Cephalexin (antibiotic to treat UTI) 250 mg (milligram-unit of measure) 1 capsule by mouth daily indefinitely…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$4,893 in federal fines across 2 penalties.
- $1,748 — penalty dated 2023-09-18
- $3,145 — penalty dated 2023-08-28
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to GENERATIONS HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.1 | ≈ chain avg |
| Health inspection | 4 of 5 | 3.6 | +0.4 vs chain |
| Staffing | 4 of 5 | 3.7 | +0.3 vs chain |
| Quality measures | 3 of 5 | 4.6 | -1.6 vs chain |
The other 26 homes this chain runs (chain average 4.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MASTROCOLA, LOIS | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 9% | since 11/01/2012 |
| OLDS, THOMAS | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 78% | since 11/01/2012 |
| BMO BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER SECURITY INTEREST | — | since 10/06/2021 |
| HALL, MARK | Individual | W-2 MANAGING EMPLOYEE | — | since 04/28/2022 |
| LIFE GENERATIONS HEALTHCARE, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/16/2012 |
CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555830. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-21, 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.