Atlantic Memorial Healthcare Center
2750 Atlantic Avenue, Long Beach, CA 90806 · For profit - Corporation · 104 certified beds · (562) 424-8101 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (19% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.6% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.8% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.2% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 9.7% | 7.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 1.6% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 6.2% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.9% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.1% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 0.9% | 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 | 12.5% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.1% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 3.1% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.31 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.45 | 1.57 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
45.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 160 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.7% 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 99 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 0.84 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 23% 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 | 45.4%CMS range 38.4–51.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 7.7–13.7 | 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 | 65.7% | 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 | 56.6% | 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 | 48.5% | 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 | 99.4% | 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 | 98.4% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.1% | 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 | 11.1%CMS range 8.2–15.1 | 7.1% | Oct 2023–Sep 2024 | worse than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.47 | 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 104 beds and averages 85.3 residents a day — about 82% occupied, or roughly 19 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 4.41 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.80 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 3.95 hrs/resident/day on weekends vs 4.59 on weekdays — 14% thinner on weekends. RN hours go from 0.56 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 19% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · D2026-06-16 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received effective pain management by failing to ensure Licensed Vocational Nurse (LVN) 1 addressed Resident 1's pain when the resident developed dysuria (painful urination) on 6/10/2026.This failure put Resident 1 at risk of unrelieved pain and for delay of care.During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE] to the facility with diagnoses including Parkinson's Disease(a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), myasthenia gravis(chronic autoimmune[ body gets confused and produces proteins that attack normal cells]disorder that causes muscles to feel weak and tire out easily), hypertension(HTN- high blood pressure), and chronic kidney disease(kidneys are damaged and lose their ability 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 · Ecited before2026-03-13 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their policy and procedures (P&P) to maintain and observe infection control practices by failing to:1. Ensure Resident 69 was on airborne isolation (a set of infection-control measures used in hospitals to prevent the spread of diseases caused by tiny germs that can float in the air and travel long distances) precautions for shingles (painful, blistering skin rash).2. Ensure Medication Cart 1 B was kept clean and in sanitary condition.These failures had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and placed all residents at risk for spread of infection.Findings: 1. During a review of Resident 69's admission Record, the admission Record indicated Resident 69 was admitted to the facility on [DATE] with diagnoses including immunodeficiency (a group of conditions that make it hard for the body to fight infections) and malignant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-13 · 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, interviews, and record review, the facility failed to ensure staff prepared and handled ready-to-eat foods (any food intended to be eaten without needing further cooking, washing, or preparation to make it safe) using sanitary practices and maintain proper cold handling temperatures for potentially hazardous foods (items that support rapid bacterial growth and require strict temperature controls).These failures had the potential to result in foodborne illnesses (any illness resulting from eating contaminated/spoiled foods), which could result in serious complications for all residents in the facility including hospitalization or death.Findings:During a concurrent observation and interview on 03/112026 at 11:55 a.m. with cook (CK) 1, CK 1 was observed preparing a peanut butter and jelly sandwich. CK 1 was observed spreading peanut butter and jelly onto bread using bare hands without wearing gloves or utilizing utensils to prevent direct hand contact with ready-to-eat food. CK 1 acknowledged that gloves should be worn when handling ready-to-eat food. CK 1 stated…
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 before2025-04-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a resident centered Care Plan for one of three sampled residents (Resident 1) who had a diagnosis of left upper extremity (LUE) deep vein thrombosis ([DVT] a blood clot in a deep vein). The facility failed to: 1. Implement Resident 1's Responsible Party (RP) 1 request to display signage over Resident 1 ' s bed instructing nursing staff to avoid taking blood pressures in Resident 1's left upper extremity. 2. Ensure Resident 1's Care Plan included the location of Resident 1's DVT to include the LUE and specific instructions on how to assess for complications of a DVT, which included assessment of the area to detect pain, swelling, warmth, and discoloration in the affected extremity, as well as signs of pulmonary embolism ([PE] a serious condition where a blood clot or other substance obstructs an artery in the lungs, blocking blood flow and oxygen delivery, which are usually caused by a DVT) such as difficulty…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-24 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Define resident-specific, objectively measurable target behaviors related to the use of risperidone (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 16.) 2. Ensure divalproex (a medication used to treat mood swings) was used only for conditions or diagnoses as documented in the clinical record in one of five residents sampled for unnecessary medications (Resident 16.) 3. Failing to define specific measurable target behaviors and to ensure a resident did not receive routine psychotropic medication (any medication capable of affecting the mind, emotions, and behavior) unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record for Resident 43 and Resident 10. This failure had the potential to result in the use of unnecessary psychotropic medication for Resident 43 and 10 that can lead to side effects and adverse consequences…
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 · D2025-01-24 · 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 obtain informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with divalproex (a medication used to treat mood swings) in one of five residents sampled for unnecessary medications (Resident 16). This failure of failing to obtain informed consent prior to initiating treatment with medications used to treat problematic behaviors could have prevented Resident 16 from exercising his right to decline treatment with divalproex. This increased the risk that Resident 16 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to divalproex, such as drowsiness, dizziness, and increased risk of falling, possibly leading to impairment or decline in his…
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 before2025-01-24 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered and individualized care plan for one of two sampled residents (Resident 63) who was unvaccinated (not having received a vaccine) and exposed to Influenza A (a contagious viral infection that attacks the respiratory system and can cause widespread outbreak). This failure had the potential to result in an inadequate monitoring, and not receiving care specific to resident's needs causing a delay of care to Resident 63. Findings: During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). During a review of Resident 63's Minimum Data Set (MDS- a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-24 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure 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 ensure communication device (communication board) are accessible to residents for one of four sampled residents (Resident 42) who was nonverbal and lack the capacity to speak. This failure had the potential of placing Resident 42 at risk of not able to communicate needs to staff and misinterpretation. Findings: During a review of Resident 42's admission Records, the admission Record indicated Resident 42 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cognitive (ability to think, understand, learn, and remember) communication deficit (difficulty in communicating effectively due to impairments in cognitive processes like attention, memory, reasoning, organization, and perception) and dysphagia (difficulty swallowing). During a review of Resident 42's Minimum Data Set ([MDS] resident assessment tool) dated11/12/2024, the MDS indicated Resident 42's daily decision-making skills were severely…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide activities of daily living (activities related to personal care including bathing, showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) to one of four sampled residents (Resident 51). Facility failed to: a. Provide personal hygiene to Resident 51 b. Provide assistance to Resident 51 with morning care, personal hygiene and setting up breakfast tray. This deficient practice resulted in Resident 51 expressing feelings of unkempt, hands dirty, did not feel comfortable eating breakfast in the morning, and low self-esteem. Findings: a. During a review of Resident 51's admission Records, admission Record indicated Resident 51 was initially admitted to facility on 3/19/2024 and readmitted on [DATE] with diagnoses including urinary tract infection (infection of the bladder), abnormalities of gait, need for assistance with activities of daily living (ADL) During a review of the Minimum Data Set…
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 · D2025-01-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary service and care on one of four sampled residents ( Resident 18 and Resident 45) by failing to: 1.Monitor occurrence of bowel movement(movement of feces through the bowel and out the anus) for Resident 79 and provide necessary medications for constipation( a condition in which stool becomes hard, dry, difficult to pass and bowel movements become infrequent) as ordered by the physician. This failure had the potential to put Resident 79 at risk for fecal impaction (hardened stool that's stuck in the rectum or lower colon) that could lead to bowel obstruction(partial or complete blockage of small or large intestines which is life threatening). Findings: During a review of Resident 79's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included myocardial infarction (MI-heart attack), asthma(chronic lung disease caused by swelling and muscle tightening around 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.
Show the remaining 15 citations
- Potential for harm · Dcited before2025-01-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a resident received continuous oxygen as ordered by the physician for two of three sampled residents (Resident 48 and Resident 70) by: a. Failing to ensure Resident 48 received oxygen at two liters per minute (lpm) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) continuously as ordered by the physician. b. Resident 70 nasal cannula was connected to an oxygen concentrator (medical device that help you take in oxygen) These failures had the potential to result in Resident 48 and Resident 70 receiving inaccurate amount of oxygen and cause complications associated with oxygen therapy. Findings: During a review of Resident 48's admission Record, the admission Record indicated, Resident 48 was initially admitted to the facility on [DATE] and last re-admission was on 3/23/2023 with diagnoses including malignant neoplasm(cancer) of right lung and chronic obstructive…
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 · D2025-01-24 · 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, interview, and record review, the facility failed to accurately account for one dose of hydrocodone/apap (a controlled medication used to treat pain) 10/325 milligrams (mg - a unit of measure for mass) affecting Resident 190 in one of two inspected medication carts (Station 1B Cart.) This failure increased the risk of diversion (any use other than that intended by the prescriber) of controlled medications and the risk that Resident 190 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: During a concurrent observation interview on 1/22/25 at 11:04 a.m. with the Licensed Vocational Nurse (LVN 1), observed Station 1B Cart, the following discrepancies were found between the Controlled Medication Count Sheet (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual…
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 · D2025-01-24 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for one of 21 sampled residents (Resident 6 and Resident 242). Resident 6 and Resident 242 was prescribed an antibiotic drug without meeting the Mc Geer Criteria (a set of clinical definitions used for surveillance in long-term care facilities (LTCF) These criteria define the resident symptoms and other clinical criteria that are used to meet infection surveillance definitions.). This failure had the potential to result in Resident 6 and Resident 242 developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 6's admission Record, the admission record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to a chronic ulcer (a non-healing wound on the skin) of the buttock, duodenal ulcer (a sore in the first part of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-24 · 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 interview and record review, the facility failed to ensure one of four sampled residents (Resident 79) Medication Administration Record(MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) indicated Resident 79 did not receive his medication on 1/21/2025 for 9:00 a.m. due to nausea and vomiting. This failure indicated an inaccurate Medication Administration Record and had the potential to negatively affect Resident 79's care. Findings: During a review of Resident 79's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included myocardial infarction (MI-heart attack), asthma( chronic lung disease caused by swelling and muscle tightening around the airways), sequelae of cerebral infarction (aftermath of a stroke) and hypertension(HTN-high blood pressure). During a review of Resident 79's MDS dated [DATE], the MDS indicated the resident had impaired cognitive skills and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-24 · 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 observe infection control practices by failing to: a. Ensure Resident 70's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was kept in a sanitary manner. b. Ensure positive result of Influenza test (test to detect the presence of flu virus) of Resident 79 was relayed to the physician in a timely manner. c. Ensure droplet precaution (actions designed to reduce/prevent transmission of viruses spread or transmittable through air droplets by coughing, sneezing, talking and close contact with an infected patient's breathing) was initiated and observed when Resident 70 tested positive for Influenza A (Flu- a contagious viral infection that attacks the respiratory system and can cause widespread outbreak) and symptomatic (showing symptoms of flu). These failures had the potential to transmit and spread infection to residents, visitors, and staff. Findings: a.During a review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) for one of five sampled residents (Resident 6). This failure had the potential to result in Resident 6 developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic ulcer (a non-healing wound on the skin) of the buttock, duodenal ulcer (a sore in the first part of the small intestines) and rectal fistula (an infected anal gland that forms an abscess). During a review of Resident 6's History and Physical (H&P), dated 3/27/2024, the H&P indicated Resident 6 was able to make his own medical decisions. During a review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-27 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 address one of three sampled residents ' (Resident 1) concerns with documented resolution and follow up. This failure had the potential to violate the resident ' s right to have their grievance addressed. Findings: During a review of Resident 1's admission Record, dated 7/15/2024, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including ESRD (End Stage Renal Disease-irreversible kidney failure), anxiety disorder, major depressive disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 6/30/2024, the MDS indicated Resident 1 had the cognition (ability to learn reason, remember, understand, and make decisions) to recall information after cueing or prompting and required supervision or contact guard (minimal touching for stability) assistance when walking. 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.
- Potential for harm · D2024-11-13 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to revise a resident centered care plan for one of three sampled residents (Resident 1) who was at risk for developing permanent foot drop (difficulty in lifting the front part of the foot) extremity by failing to: a. Ensure Resident 1's responsible party (RP) 1 received clear and consistent communication from the Interdisciplinary Team ([IDT] health care professionals who work together with the resident and or RP to plan the residents plan of care) summarizing the changes in Resident 1's insurance payer sources and how it would affect Resident 1's physical therapy plan. b. Ensure all members of Resident 1's direct care team (bedside licensed nurses, Certified Nurse Assistants [CNAs] and Restorative Nurse Assistants [RNA] were provided education on how and when to use the Ankle Foot Orthosis ([AFO]custom made orthotic [provides support to joints] device to provide support and stabilize the lower extremity encompassing the foot, ankle and leg…
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 · E2024-01-26 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow through with the Preadmission Screening and Resident Review ([PASRR] guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility (NF) be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness, intellectual disability, to ensure their needs will be met ) recommendation to obtain a PASRR level II (results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care) evaluation for two (2) of 19 sampled residents (Residents 12 and 64) who was diagnosed with a mental illness prior to admission in the facility. This deficient practice had the potential to result in inappropriate placement, and Residents 12 and 64 not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility. Findings: A.During a review of Resident 64's admission Record, dated…
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 before2024-01-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedure for dating oxygen tubing and nasal cannula (([NC], a device that deliver extra oxygen through a tube and into the nose) by ensuring the oxygen tubing was maintained weekly for three (3) of 19 sampled residents (Residents 33, 12 and 235) who were receiving oxygen therapy. This deficient practice placed residents at risk of respiratory infections by directly transferring potentially pathogenic (disease causing) organisms through the tubing onto the mucous membranes (moist inner lining of body cavities such as the nose) inside the residents' nasal passages, causing complications associated with oxygen therapy. Findings: A. During an observation on 1/23/2024 at 8:44 a.m. during the initial tour, Resident 33's oxygen nasal tubing that was not labeled or dated and was on Resident 33's bedside table. During a review of Resident 33's admission Record dated 11/29/2017, the admission Record indicated Resident 33…
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 · E2024-01-26 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 maintain safe proper storage of medications, document medications after administration and secure controlled medications by: 1. Failing to ensure the antibiotic medication count sheet for two (2) of two residents (Resident 34 and Resident 44) was signed after medication administration. 2. Failing to ensure the emergency kit #87([E-kit] a small quantity of medications that can be dispensed when pharmacy services are not available) was sealed and locked in the medication storage room. These deficient practices had the potential for medication dispensing errors, theft or diversion for controlled medications and placed staff and residents at risk for unsafe medication administration. Findings: 1. During a concurrent observation and record review on 1/25/2024 at 12:12 pm, with Licensed Vocational Nurse (LVN 4), of medication cart number two, LVN 4 stated, she administered antibiotics (medications used to treat infections) to Resident 34 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 · E2024-01-26 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide two of 10 sampled residents (Resident 59 and Resident 4) a mechanical soft diet (a diet that was designed for people who have trouble chewing and swallowing) with chopped food items as ordered by the physician. This failure had the potential to result in accidents such as choking and aspirating (food, liquid, or other material enters a person's airway and eventually the lungs by accident, causing infections). Findings: During a review of Resident 59's admission Record, the admission Record indicated, Resident 59 was initially admitted to the facility on [DATE] and last admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 59's History 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 before2024-01-26 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of infectious agents that could cause food borne illness (food poisoning: any illness resulting from the food spoilage or contaminated food) for 84 out 88 total residents in the facility by not: 1. Ensure Foods were dated, labeled, and discarded before the used by date (expiration dates). 2. Monitoring and maintaining the proper level of the concentration of the quaternary ammonium (a type of chemical that is used to kill bacteria, viruses, and mold) in the sanitization bucket. 3. Monitoring and maintaining minimum safe food serving temperature of 160-degree Fahrenheit ([F]- A temperature scale according to which water freezes at 32 degrees and boils at 212 degrees.) for cooked whole chicken breasts and chopped chicken breasts during trayline (Resident's meal trays are assembled and checked for accuracy before the food is delivered to them). This failure had the potential to affect residents and result in pathogen (germ) exposure and placed residents at risk…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-26 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to provide for one (1) of 19 sampled residents (Resident 29) an ongoing program to support the resident in a choice of activities such as activities, regular room visits. This deficient practice has the potential to cause psychosocial harm and feelings of isolation for Resident 29 and further exacerbations (negative feeling) of depression and anxiety. Findings: During a review of Resident 29's admission Record dated 10/17/2023, the admission Record indicated Resident 29 was admitted to the facility with diagnoses of anxiety (a feeling of worry or nervousness), gallbladder (a small sac-shaped organ that stores digestive fluids) cancer, and gait and mobility abnormalities (unable to walk). During a review of Resident 29's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 11/17/2023, the MDS indicated that resident 29 had completely intact cognition (mental process of thinking and understanding) to make daily decisions for Activities of Daily Living (ADL's toileting, grooming, eating 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 · D2024-01-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 and interview the facility failed to ensure a safe, hazard free environment as evidenced by topical medication left in a medication cup at the bedside of one of one Residents (Resident 81). This deficient practice placed Resident 81 and other residents of the facility at risk of adverse effects due to misuse of the medication left at the bedside table. Findings: During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (a disease caused by disrupted blood flow to the brain which may cause parts of the brain to die off), hypokalemia (low potassium [essential substance to maintain health] level in the bloodstream), and cognitive (the ability to think and process information) communication deficit. During a review of Resident 81's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/08/2024, the MDS indicated, Resident 81's cognitive skills was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.2 | +1.8 vs chain |
| Health inspection | 5 of 5 | 2.8 | +2.2 vs chain |
| Staffing | 4 of 5 | 2.7 | +1.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GHATAN, BIJAN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/27/2023 |
| WILLIAMS, WILESTELA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/16/2015 |
| WILLITS, ADAM | Individual | CORPORATE DIRECTOR | since 07/01/2002 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | since 02/01/2006 |
| KIM, JESSE | Individual | CORPORATE OFFICER | since 01/01/2023 |
| PORT, BARRY | Individual | CORPORATE OFFICER | since 07/01/2002 |
| SATO, AMI | Individual | CORPORATE OFFICER | since 09/09/2024 |
| CARETRUST GP LLC | Organization | ADP OF THE SNF | since 07/01/2002 |
| CARETRUST REIT INC | Organization | ADP OF THE SNF | since 07/01/2002 |
| CTR PARTNERSHIP LP | Organization | ADP OF THE SNF | since 07/01/2002 |
| QUEENSWAY HEALTH HOLDINGS LLC | Organization | ADP OF THE SNF | since 07/01/2002 |
CMS files one row per role, so the 15 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.5M 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 055744. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-13, 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 →
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