No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Long Beach Post Acute

1201 Walnut Avenue, Long Beach, CA 90813 · For profit - Corporation · 78 certified beds · (562) 591-7621 Medicare & Medicaid certified

Call the home — (562) 591-7621 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 27 lower-level deficiencies on record (see below)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (27) — 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.

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

Location & what’s nearby

Urgent care / clinic
1862 E Anaheim St · (562) 218-4298 · Call to confirm hours
Pharmacy
1942 E Anaheim St · (562) 591-0549 · Call to confirm hours
Grocery
1139 Gardenia Ave · (562) 474-7436 · Call to confirm hours
Park
1323 Gundry Ave · Typically dawn to dusk
Place of worship
1800 E Anaheim St · (562) 218-5702

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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.7%10.2%15.4%better
Long-stay residents who lose too much weight0.0%4.0%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms9.6%7.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened6.0%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication52.0%13.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers0.0%4.3%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control0.4%10.2%21.2%better than state — see note marked double-dagger below the table
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission30.5%23.0%22.6%worse
Short-stay residents with an outpatient ER visit5.2%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days1.452.251.67better
Long-stay outpatient ER visits per 1,000 resident days0.051.571.80better

* 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.

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.

38.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 159 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

38.9%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
94.7%U.S. median 56.6%
Met the expected recovery
0.55U.S. median 0.31
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 94.7% 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 114 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF38.9%CMS range 29.6–47.451.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.1–14.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge94.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge93.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge93.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.3%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.7%CMS range 2.4–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.451.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.51
RN hours/ resident / day
0.92
LPN hours/ resident / day
2.87
Aide hours/ resident / day
4.30
Total nurse hours/ resident / day
0.40
RN hoursweekends
29.2%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 78 beds and averages 66.8 residents a day — about 86% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.30 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.87 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 3.94 hrs/resident/day on weekends vs 4.45 on weekdays — 11% thinner on weekends. RN hours go from 0.56 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% 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

4
deficiencies at the latest standard inspection (2026-01-15)
6
at the previous standard inspection (2024-10-03)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Dcited before2026-06-12 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Social Service Director (SSD) documented services provided to the Emergency Contact (EC) 1 for one of five sampled residents (Resident 1) when EC 1 was assisted and updated in initiating a guardianship (an evaluation conducted to determine whether the individual needs assistance with decision making or with accomplishing activities of daily living) evaluation and completing documents necessary for guardianship.This failure has resulted in undetermined efforts of the facility in assisting EC 1 of the guardianship evaluation and had the potential for EC 1 to miss updates of the process requested.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 was admitted to the facility with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depression (feelings of constant sadness and loss of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-05 · tag F0552 — isolated
    Ensure 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 an informed consent was obtained prior to administering amphetamine-dextroamphetamine ([Adderall] a psychotropic [any drug that affects a person's mental state, emotions, thoughts, or behavior] medication used to treat attention-deficit hyperactivity disorder [ADHD - a condition that makes it difficult to focus, stay organized and control restlessness) for one of four sampled residents (Resident 1).This failure resulted in Resident 1 receiving Adderall without documented informed consent, and without being informed of the medication's purpose, dose, risks, benefits and alternatives prior to administration. This failure had the potential for Resident 1 to receive unnecessary medications. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including generalized anxiety disorder (extreme worry), major depressive disorder (a mood…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-05 · tag F0585 — failed to handle grievances — isolated
    Honor 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 observation, interview, and record review, the facility failed to ensure the grievance process was followed for one of four sampled residents (Resident 1).This failure resulted in Resident 1's grievance regarding food preferences being marked resolved without the identified problem being corrected, without the responsible department being notified, and without follow-up to verify resolution. This failure resulted in Resident 1 continuing to receive unwanted processed deli meats after the grievance was filed and had the potential to negatively impact Resident 1's health and well-being. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including attention-deficit hyperactivity disorder ([ADHD] a condition that makes it difficult to focus, stay organized and control restlessness), functional dyspepsia (ongoing stomach discomfort such as fullness, bloating, or mild pain without a clear…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-05 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a resident assessment tool) accurately reflected the active diagnoses of one of four sampled residents (Resident 1). This failure resulted in inaccurate diagnoses, incomplete nutritional assessments, and Care Plans that did not reflect Resident 1's gastric sleeve surgery (a surgery which permanently reduces stomach size and affects how much and what types of food the resident can tolerate), loose teeth, autism diagnosis (a developmental condition that affects how the resident understands information, communicates, interacts with others, and responds to sensory input), history of eating disorders, chewing problems, or food intolerances. These failures had the potential to negatively affect Resident 1's nutritional management, dietary tolerance, and individualized plan of care. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered Care Plan for Resident 1's autism (a developmental condition that affects how the resident understands information, communicates, interacts with others, and responds to sensory input) and bathing preferences/barriers for one of four sampled residents (Resident 1). This failure resulted in Resident 1's Care Plans not reflecting individualized interventions for cognitive, behavioral, hygiene, and physical care needs. This failure had the potential to negatively affect Resident 1's individualized care, hygiene, and overall well-being.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses generalized anxiety disorder (ongoing excessive worry or nervousness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) , insomnia (trouble…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff consistently identified, documented, and addressed the reasons for one of four sampled residents (Resident 1) repeated refusals of scheduled showers, and implement alternative approaches to provide adequate bathing and hygiene care. This failure resulted in Resident 1 not receiving showers for an extended period and had the potential to affect Resident 1's dignity and increase the risk for poor hygiene, skin breakdown, and infection.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnosis including muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (a decrease in size or wasting away of a body part or tissue), abnormalities of gait and mobility (difficulty walking or moving in a normal, safe, or steady way), generalized anxiety disorder (ongoing excessive worry or nervousness), and attention-deficit…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-05 · tag F0800 — isolated
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary 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 ensure the Registered Dietician (RD) and Dietary Supervisor (DS) completed a comprehensive and accurate nutritional assessment for one of four sampled residents (Resident 1) to meet their individualized needs and dietary preferences. This failure resulted in Resident 1 receiving meals which did not align with her stated food preferences and nutritional needs. This failure had the potential to negatively affect Resident 1's nutritional status and dietary management due to autism (a developmental condition that affects how the resident understands information, communicates, interacts with others, and responds to sensory input), gastric sleeve surgery (a procedure which permanently reduces stomach size and affects how much and what types of food the resident can tolerate), loose teeth, history of eating disorders, and documented food preferences.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-05 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff accurately documented when a resident (Resident 1) refused therapy and when Resident 1 was notified that her therapy services were discontinued for one of four sampled residents (Resident 1). This deficient practice resulted in an incomplete clinical record and had the potential to negatively affect Resident 1's continuity of care, care planning, skilled coverage decision-making, and the facility's ability to evaluate the appropriateness of therapy discontinuation.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (a decrease in size or wasting away of a body part or tissue), abnormalities of gait and mobility (difficulty walking or moving in a normal, safe, or steady way), pain in right leg, chronic pain, muscle spasm (sudden tightening and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-15 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the storage of food was done under sanitary conditions in one of one kitchen by not labeling an opened food item with a date opened and prepared food items with date prepared.These deficient practices had the potential to cause food-borne illnesses (any illness resulting from eating contaminated/spoiled foods).Findings:During a concurrent observation and interview on 1/12/2026 at 8:26 a.m., with the Dietary Supervisor (DS) in the dry storage room, a previously opened gallon container of sesame oil was without a label of open date. The DS stated the oil did not have an open date. There was a serving tray on top of a storage bin that had five prepared bowl containers of dry cereal with no label of date prepared. During an interview on 1/14/2026 at 11:53 a.m., with the Registered Dietician (RD), the RD stated opened food items should be dated and labeledDuring a review of the facility's policy and procedure (P&P), titled Labeling and Dating of Foods, dated 20203 The P&P indicated all food items in the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a person-centered care plan was developed and implemented for Risperdal [anti-psychotic medication (used to manage psychosis symptoms)] for one of four sampled residents (Resident 5). This deficient practice has the potential to result in unnecessary medication use, unmonitored side effects and decline in functional status. Findings:During a review of Resident 5's admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 5/5/2025 with diagnoses including peripheral autonomic neuropathy (damage to automatic body nerves for unknown reasons), hypotension (low blood pressure), paranoid schizophrenia (brain disorder where a person may hear or see things that are not real), schizoaffective disorder (condition where someone's thoughts get mixed up and their mood swings are very strong and hard to control), and hyperglycemia (high blood sugar).During a review of Resident 25's History and Physical (H&P) dated 5/6/2025, the H&P indicated Resident 25 has fluctuating…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2026-01-15 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the nursing staff failed to revise a care plan for impaired communication for one of four sampled residents (Resident 30) who was deaf (condition where an individual has a significant or complete inability to speak) and non-verbal. This deficient practice had the potential for Resident 30's needs not to be met, due to her inability to express them.During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hearing loss, non-verbal, and idiopathic peripheral autonomic neuropathy (IPAN: nerve damage affecting automatic functions (heart rate, blood pressure [amount of pressure that takes the heart to pump blood in the body], digestion). During a review of Resident 30's History and Physical (H&P), dated 7/25/2025, the H&P indicated Resident 30 had the capacity to understand and make decisions. During a review of Resident 30's 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-15 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document nursing assessment for the use of Continuous Positive Airway Pressure (CPAP, a machine that delivers air through a mask to keep the airway open during sleep and prevent breathing pauses) for one of three sampled residents (Resident 78). This deficient practice had the potential to result in inaccurate and incomplete resident records and delayed identification of respiratory support needs. Findings:During a review of Resident 78's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 1/9/2026, with diagnoses including alcohol dependence, nicotine dependence, major depressive disorder (mood disorder characterized by persistent sadness and loss of interest in daily activities) and insomnia (trouble falling asleep or staying asleep).During a review of Resident 78's Minimum Data Set (MDS, a resident assessment tool), dated 1/15/2026, the MDS indicated Resident 78 had intact cognition (ability to think…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident, who was newly admitted to the facility, from a psychiatric facility, was supervised, and monitored to prevent one out of three sampled residents (Resident 1) from eloping (leaving a secured institution without notice or permission) from the facility. Resident 1 was last seen in the facility on 10/4/2024 at approximately 8:30 p.m., on the facility ' s patio, smoking. Resident 1 was noted missing on 10/4/2024 at approximately 9 p.m., and found at his family ' s residence, 22 miles away on 10/5/2024 at 5:30 a.m. This deficient practice resulted in Resident 1 eloping from the facility on 10/4/2024 at approximately 9 p.m. and missing for over eight hours. This deficient practice had the potential for Resident 1 ' s whereabouts to continue to be unknown, for Resident 1 to be exposed to excessive drops in temperature, motor vehicle accidents, hunger, dehydration, and death. Findings: During a review of Resident 1 ' s admission Record (Face…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-10-03 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions for 63 of 63 residents by not: 1. Labeling perishable food items (two open pasta bags) with open date. 2.Thawing diced beef according to facility policy. These deficient practices had the potential to cause food-borne illnesses. Findings: During a concurrent observation and interview on 9/30/2024 at 8:45 a.m., with the Dietary Supervisor (DS) in the dry storage room, two bags of dried pasta (one macaroni and one farfalle) were previously opened without an open date. The DS stated the bags did not have an open date. During an observation on 10/1/2024 at 11:45 a.m., in the kitchen meal prep sink, three bags of meat were sitting in a tray of still (not running) water. The sink faucet was off. During a concurrent observation and interview on 10/1/2024 at 12:13 p.m., with [NAME] 1, [NAME] 1 turned on the sink faucet. [NAME] 1 stated the bagged meat was diced beef for tomorrow's lunch. [NAME] 1 stated the water was running…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-03 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: a. Ensure one of four sampled residents (Resident 116)'s narcotic (drug that affects mood or behavior) was documented in the narcotic record when it was administered on 9/11/2024 at 5 pm. b. Ensure one of three sampled resident's (Resident 53)'s home medications were documented when facility staff received it. These deficient practices had the potential to result in medication errors and drug diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of narcotics. Findings: a. During a review of Resident 116's admission Record, the record indicated Resident 116 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental health disorder that affects the mood and behavior), depressive episodes (feeling sad, irritable, and empty), and generalized anxiety disorder (a mental health condition that causes people to experience excessive,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-03 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 two residents (Resident 61), who was diagnosed with post-traumatic stress disorder (PTSD - mental health condition that can develop after someone experiences a deeply distressing or disturbing event), received trauma informed care (a model that aims to provide effective mental health services by taking into account a person's past experiences with trauma). This deficient practice had the potential to result in resident 61's re-traumatization and can be detrimental for the resident's psychosocial status. Findings: During a review of Resident 61's admission Record, the record indicated Resident 61 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (mental health disorder that can cause people to lose touch with reality), major depressive disorder (mental health condition characterized by persistent sadness or loss of interest in activities), anxiety disorder (mental health condition that causes people to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-03 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each 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 up and ensure one of eight sampled residents (Resident 7) received follow up dental care recommended by the dentist. This deficient practice had the potential to cause further decline in Resident 7's teeth and dental pain. Findings: During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), generalized anxiety disorder (a mental health condition that causes people to experience excessive, uncontrollable, and irrational worry about everyday things), and depression (a mental state that can affect a person's thoughts, feelings, behavior, and sense of well-being). During a review of Resident 7's Oral/Dental care plan dated 4/7/2024, the care…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-03 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure 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 serve a snack that was prepared as prescribed by the physician for one of two sampled residents (Resident 33). This deficient practice had the potential to cause the resident to choke on their food. Findings: During a review of Resident 33's admission Record, dated 9/22/2024, the admission Record indicated Resident 33 was initially admitted to the facility on [DATE] with diagnoses including Dysphagia (difficulty swallowing). During a review of Resident 33's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/19/2024, the MDS indicated Resident 33 was cognitively (ability to make decisions of daily living) intact and able to recall recent events During a review of Resident 33's physician orders, dated 9/13/2024, the order sheet indicated Resident 33 was prescribed a pureed (consisting of foods that are ground, pressed, or strained until they have a smooth, soft consistency, similar to pudding) texture regular…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-03 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure to document the visual monitoring for behaviors, every 15 minutes for one of one resident's (Resident 113)'s medical records. The deficient practice indicated an inaccurate account of care and services received by Resident 113, and the inability of the facility to recognize and act on trends of Resident 113's behaviors. Findings: During a review of Resident 113's admission Record, the record indicated Resident 113 was admitted to the facility on [DATE] with diagnoses including schizophrenia (mental health disorder that can cause people to lose touch with reality), depressive episodes (feelings of sadness, tearfulness, emptiness, or hopelessness), and generalized anxiety disorder (mental health condition that causes people to experience excessive, persistent, and uncontrollable worry). During a review of Resident 113's Minimum data Set (MDS), a federally mandated assessment tool, dated 10/1/2024, the MDS indicated Resident 113's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-10-06 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a specialized tool due to its small size) that could cause food borne illness (food poisoning: illness due to consuming spoiled food) for residents in the facility by not: a. ensuring Strawberry ready care shakes (nutritional shake that gets delivered frozen) were dated, when placed in the refrigerator to thaw (once thawed, shelf life is less than 14 days) b. ensuring a salad and bowl of lettuce was labeled and dated in the refrigerator. c.ensuring a bowl of tuna salad, a container of cornflakes, and a tupperware of peaches were not expired. c.ensuring the ice machine was maintained in a clean and sanitary way These deficient practices had the potential to affect residents of the facility and result in pathogen (germ) exposure, and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-10-06 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to observe infection control measures by failing to ensure the dryer was running at the proper temperature. This deficient practice had the potential to place residents at risk for infection. Findings: During observations on 10/3/2023, at 3:50 pm, on 10/5/2023, at 8:16 am and at 9:00 am, the dryer temperature was reading between 124 to 128 degrees Fahrenheit ([F] scale of measuring temperature), loud and rattling noise was heard at the back of one of the dryers during the drying cycle. During an interview on 10/3/2023, at 8:16 a.m. with Laundry Aide (LA1), LA 1 stated the temperature of the dryer should be 160 degrees F to 180 degrees F to kill bacteria on the linens and clothes. During an interview on 10/3/2023, at 8:34 a.m. with Maintenance Supervisor (MS), MS stated the temperature of the dryer should be maintained between 160 to 180 degrees F to kill the bacteria and prevent spread of infection among residents. MS stated a laundry technician came to check and fixed both dryers last 9/20/2023 because the dryers…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-06 · tag F0745 — failed to provide medically-related social services — pattern
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 the necessary social services for five of 15 sampled residents (Resident 38, Resident 40, Resident 42, Resident 47, Resident 53) by : a. not following up on an ophthalmology consultation recommendation to adjust new glasses for Resident 38. b. not following up on a dental recommendation for a full mouth x-ray and dentures for Resident 40. c. not ensuring Resident 42 was initially assessed and received individualized intervention to meet his mental and psychosocial needs. d. not following up on dental recommendations for a full mouth x-ray for Resident 47. e. not following up on an optometrist consultation for new reading glasses for Resident 53. This failure resulted in a delay of care and services. Findings: a. During a review of Resident 38's Face Sheet, the Face Sheet indicated, Resident 38 had diagnoses of but not limited to malignant (spreads fast) neoplasm (a type of abnormal and excessive growth of tissue) of the mouth,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-06 · tag F0791 — failed to provide routine dental services — pattern
    Provide or obtain dental services for each 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 provide routine dental service for three of 15 residents (Resident 40, Resident 47, and Resident 53). This failure resulted in Resident 40 and Resident 47 not receiving a recommended full mouth x-ray and Resident 53 not receiving new dentures. Findings: a. During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40 was admitted on [DATE] with diagnoses of but not limited to osteoarthritis (a type of degenerative joint disease that results from breakdown of joint and underlying bone), anemia (a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of blood cells), dementia (a decline in cognitive abilities that impacts a person's ability to perform every day activities), muscle wasting and atrophy. During a review of Resident 40's H&P dated 4/27/2023, the H&P indicated Resident 40 did not have the mental capacity to make decisions. During a review of Resident 40'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-06 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to provide privacy for one of 15 sampled residents (Resident 38) by discussing care and treatment of Resident 38 at the nurse's station in the presence of staff and other residents. This deficient practice had the potential to result in embarrassment and reveal private information for Resident 38. Findings: During a review of Resident 38's Face Sheet, the Face Sheet indicated, Resident 38 had diagnoses of but not limited to malignant (spreads fast) neoplasm (a type of abnormal and excessive growth of tissue) of the mouth, major depressive disorder (a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of pleasure in normally enjoyable activities), muscle wasting (a condition where muscles lose mass and strength) and atrophy (decrease in size or wasting away of a body part or tissue). During a review of Resident 38's History and Physical (H&P), dated 2/14/2023, the H&P indicated, Resident 38 had the mental capacity to understand and make decisions. During a review of Resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-06 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to initiate a person-centered care plan for one of three sampled residents (Resident 41) for missing teeth. This deficient practice had the potential for Resident 41 to not be monitored for adverse outcomes of missing teeth such as choking due to trying to swallow unchewed food. Findings: During a review of Resident 41's admission record, the admission record indicated Resident 41 was admitted to the facility on [DATE] with diagnoses including dysphagia (swallowing difficulties) and functional dyspepsia (recurring symptoms of an upset stomach that have no obvious cause). During a review of Resident 41's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/5/2023, the MDS indicated Resident 41 had the ability to makes self-understood and was able to understand others. During a review of Resident 41's Oral/ Dental Care plan (CP) initiated on 5/31/2023 and last revised on 9/2023, the CP indicated Resident 41 had a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-06 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing 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 two of 15 sampled residents (Resident 38 and Resident 53) optometrist (a healthcare professional who provides vision care) recommendations to arrange for Resident 38's new glasses, to be adjusted (to improve his sight) and to obtain new glasses for Resident 53 were followed. This failure resulted in a diminished quality of life for Resident 38 not being able to read fine print, and Resident 53 not having new glasses to maintain vision. Findings: a. During a review of Resident 38's Face Sheet, the Face Sheet indicated, Resident 38 had diagnoses of but not limited to malignant (spreads fast) neoplasm (a type of abnormal and excessive growth of tissue) of the mouth, major depressive disorder (a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of pleasure in normally enjoyable activities), muscle wasting (a condition where muscles lose mass and strength) and atrophy (decrease in size or wasting away…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-06 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to monitor and reassess pain level on one of five sampled residents (Resident 9) in accordance with the standard practice of care. This deficient practice resulted in facility staff not reassessing Resident 9's pain level in a timely manner and placing Resident 9 at risk for unnecessary pain. Findings: During a review of Resident 9's admission Record (AR), the AR indicated the resident was admitted on [DATE] to the facility with diagnoses that included diabetes (high blood sugar), chronic pain syndrome (pain that lasts for over three months and can interfere with daily activities), and hypertension (high blood pressure). During a review of Resident 9's Minimum Data Set (MDS) standardized assessment and screening tool dated 9/11/2023, the MDS indicated the resident had intact cognition (thought process) and required one-person physical assist with bed mobility, transfer, dressing, and toilet use. The MDS indicated the resident had pain…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE MANDELBAUM FAMILY — 18 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 53.2+1.8 vs chain
Health inspection 4 of 52.7+1.3 vs chain
Staffing 4 of 53.9+0.1 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 17 homes this chain runs (chain average 3.2★, 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 / managerTypeRoleShareSince
MSSM LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2023
SIMCHA AND JANET MANDELBAUM FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST10%since 09/01/2021
THE BENTZION MANDELBAUM 2021 IRREVOCABLE GIFT TRUST NO. 2Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST25%since 01/01/2023
THE JANET MANDELBAUM 2021 IRREVOCABLE GIFT TRUST NO 2Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST8%since 12/01/2021
THE SIMCHA MANDELBAUM 2021 IRREVOCABLE GIFT TRUST NO. 2Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 01/01/2023
MANDELBAUM, JANETIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2023
ALBERT, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/09/2023
CASTRO-GARCIA, MARIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/06/2019
HUANG, JIMMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/20/2019
MANDELBAUM, SIMCHAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2026
MERIDA, JASONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/27/2023
MONROY, ALEJANDROIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2017
MUNOZ, CARLOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/09/2023
PHAM, JULIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/16/2000
RAMOS, MARIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2021
SANCHEZ, RAMONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/02/2020
WILLIAMS, CLINTONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/04/2010
MANDELBAUM, BRENDAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/30/2025
1201 WALNUT AVENUE LLCOrganizationADP OF THE SNFsince 01/01/2023
HANSENOrganizationADP OF THE SNFsince 01/01/2023
SKILLSERVE INCOrganizationADP OF THE SNFsince 01/01/2023

CMS files one row per role, so the 32 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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.

$10.2M
Net patient revenuemost recent cost report
+2.1%
Operating marginrevenue minus expenses
$480K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 40%Other / private 0%

This home reported $480K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$460per resident / day
operating cost
$13,970per month
≈ monthly operating cost
$469per day
avg. revenue, all payers

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

What families pay in CA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555010. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, 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.

What to do next