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

Ararat Convalescent Hospital

2373 Colorado Blvd., Los Angeles, CA 90041 · Non profit - Corporation · 42 certified beds · (323) 256-8012 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0604) — cited Nov 20241 immediate-jeopardy citation$10,039 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0604), cited Nov 2024
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (36) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,039 in federal fines (most recent 2024-11-07)
  • its payroll-based staffing score sits well above its independent inspection score

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2560 Colorado Blvd · (323) 255-5409 · Call to confirm hours
Pharmacy
2455 Colorado Blvd Ste 6 · (323) 551-5906 · Call to confirm hours
Grocery
2455 Colorado Blvd
Park
Typically dawn to dusk
Place of worship
2424 Colorado Blvd

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 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 improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.4%10.2%15.4%better
Long-stay residents who lose too much weight4.6%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.8%1.2%2.0%better
Long-stay residents with depressive symptoms15.0%7.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury6.4%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened8.4%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.0%13.7%18.9%better
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 control8.5%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 table12.6%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents rehospitalized after admission19.7%23.0%22.6%better
Short-stay residents with an outpatient ER visit0.0%11.2%12.0%check this — see note marked star below the table
Long-stay hospitalizations per 1,000 resident days2.552.251.67worse
Long-stay outpatient ER visits per 1,000 resident days1.281.571.80better

* 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.

§ 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.

26.4% 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 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

26.4%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
52.0%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 52.0% 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 25 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 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 29% 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 SNF26.4%CMS range 16.4–44.451.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 7.7–15.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge52.0%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 discharge52.0%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 discharge48.0%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 identified100.0%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 hospitalization8.9%CMS range 4.9–15.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.311.02Oct 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

1.00
RN hours/ resident / day
0.84
LPN hours/ resident / day
2.87
Aide hours/ resident / day
4.71
Total nurse hours/ resident / day
0.42
RN hoursweekends
27.3%
Total nursing turnover
22.2%
RN turnover

How full it usually is: this home is certified for 42 beds and averages 36.8 residents a day — about 88% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.00 is at or above 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 4.18 hrs/resident/day on weekends vs 4.93 on weekdays — 15% thinner on weekends. RN hours go from 1.23 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 27% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

12
deficiencies at the latest standard inspection (2025-11-19)
7
at the previous standard inspection (2024-10-06)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

36 citations, most serious first. The 11 most serious are shown; the remaining 25 are one tap away and print in full.

  • Immediate jeopardy · J2024-11-15 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an observation, interview and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) was free from the use of physical restraints (a manual method or device that limits a person's ability to move freely), in accordance with the facility ' s policy and procedure titled Restraints by failing to: 1. Identify a situation that constitutes abuse when Certified Nurse Assistant [CNA] 1 had knowledge that Resident 1 was tied to the wheelchair with a white sheet, on 11/9/24, during the 3 PM to 11 PM shift, as evidenced by a videoclip . CNA 1 did not untie (remove) the white sheet from Resident 1 and did not report the observation to the licensed vocational nurse (LVN 1) immediately. 2. Protect Resident 1 from potential harm that could result in an injury by not responding immediately to protect Resident 1 when CNA 1 witnessed Resident 1 tied up with a white sheet to the wheelchair on 11/9/24. Instead, CNA 1 recorded a video of Resident 1 while tied up with a white sheet to 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-12 · 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 identify, assess, and investigate a potential fall for Resident 1 after the resident reported pain and stated she had fallen on 3/2/2026.Nursing staff did not initiate the facility's fall policy, including completing a post fall assessment, neurological monitoring, incident reporting, reassessment of mobility status. This failure resulted in delayed identification of injuries and placed the resident at risk for further harm, unmanaged pain, and unmet care needs.Findings: During a review of Resident 1's admission Record, the resident was noted to have been admitted on [DATE] and readmitted on [DATE], with diagnoses including multiple right sided rib fractures, pneumonia, and dementia. During a review of Resident 1's History and Physical dated 12/31/2025, the documentation indicated the resident had fluctuating capacity to understand information and make decisions. During a review of the Minimum Data Set (MDS) dated [DATE], the assessment indicated the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-19 · 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 and interview and record review the facility failed to implement the policy and procedure on food storage, in accordance with professional standards for food service safety by failing to label a used by date for the following food items: -ground meat in a plastic container -three pieces of Armenian pizza -five croissants in a clear plastic bag -five glasses of milk This deficient practice had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food and negatively affect the health of the residents who consumed it. Findings: During an initial kitchen tour and interview with the Dietary Supervisor (DS) on 9/30/2025 at 9:05 AM the following were observed without a label with a used by date. In the freezer: -In the freezer ground meat in a plastic container. -three pieces of Armenian pizza. -five croissants in a clear plastic bag. In…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-19 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the facility's policies and procedures (P&P) titled Resident Rights, dated 5/1/2023, by failing to promote privacy and dignity for two of three sampled Residents (Resident 12 and 21) by: 1.Certified Nurse Assistant (CNA 1 and 2) standing over Resident 1 while assisting with feeding Resident 21. 2.CNA 4 did not draw the privacy curtain (a curtain that tracks around the resident's bed to create a private space) fully around Resident 12's bed grooming and shaving Resident 12. These deficient practices violated Resident 21 and Resident 12's resident rights to maintain and enhance their self-esteem and self-worth and the right to be treated with dignity and respect. Findings: 1.During a review of Resident 21's, admission Record (AR), dated 10/16/2025, indicated Resident 21 was admitted to the facility on [DATE], with diagnoses that included dementia (the loss of cognitive functioning — thinking, remembering, and reasoning), heart…

    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 · D2025-11-19 · 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

    Based on interview and record review, the facility failed to implement its policy and procedures (P&P) titled Informed Consent (a voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of five sample residents (Resident 23) by not ensuring an Informed Consent was complete prior to administration of treatment of Mirtazapine (antidepressant, medication to treat depression). This deficient practice violated Resident 23 rights and her Representative Party (RP) to be informed of the risks and benefits of the proposed treatment and offered alternative treatments for Resident 23's antidepressant treatment. Findings: During a review of Resident 23's admission Records (AR), the facility admitted Resident 23 on 9/2/2024 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and unspecified mood [affective] disorder (mental health conditions that primary affect a resident's mood or emotional state). 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-19 · 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 implement a person-centered comprehensive care plan to address the resident's medical and physical needs for one of three sampled residents (Resident 9), who's cognitive skills were severely impaired, and was a high risk for fall, by not ensuring Resident 9's bed alarm (used to alert caregivers and staff when a person at risk of falls is getting out of bed) was properly working. This deficient practice had the potential to not alert the staff when Resident 9 attempted to get out of bed which could lead to a fall incident and/or injury. Findings: During a review of Resident 9's admission Record indicated the resident was admitted originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia (a decline in mental abilities that makes daily life difficult, affecting memory, thinking, and behavior), muscle weakness, abnormalities of gait and mobility and need for assistance with personal 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 facility provided necessary care and services to one of one sampled resident (Resident 22) in accordance with the facility's policy and procedure titled Care of Catheter. Resident 22's indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing was coiled and kinked obstructing the urine flow to the drainage bag. This failure had the potential for the urine to backflow to the bladder and bladder distention ( due to over accumulation of urine in the bladder) and result in catheter-associated urinary tract infection (CAUTI- an infection of the urinary system that occurs when bacteria enter through a indwelling catheter) and bladder collapse affecting the health and safety of Resident 22. Findings: During a review of Resident 22's admission Record, the admission Record indicated the facility admitted the resident on 8/5/2025, with the diagnoses including but not limited to bladder cancer, liver cancer, bile duct cancer, prostate cancer, dementia (a progressive state…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to prevent an unplanned weight loss of 15.09% in six months for one of one sampled resident (Resident 7). The facility failed to: 1.Ensure staff identified Resident 7's decrease in oral intake (amount of food and water consumed), reassess and monitor interventions for weight loss when Resident 7 had a weight loss of 16 pounds in six months. 2. Ensure staff provided Resident 7 with a nutritional supplement twice a day as per physician's order from 8/6/2025 - 10/3/2025. These failures resulted in Resident 7's severe weight loss of 6 pounds (lbs.-unit of weight) in three months and placed Resident 7 at risk for malnutrition (lack of proper nutrition, caused by not eating enough), and dehydration (dangerous loss of body fluid). Findings: During review of Resident 7's admission Record, the admission Record indicated the facility admitted the resident on 6/25/2025, with the diagnoses including but not limited to failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-19 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that three (3) Certified Nurse Assistants (CNAs) demonstrated sufficient competency and skills to accurately document the food intake of one of four sample residents (Resident 7) by evaluating their how the CNAs documented meal intakes of the residents in accordance to the facility's policy and procedures (P&P) titled, Documentation - Nursing, dated 1/1/2016 and the Guidelines for Percentage of Meal Intake. This deficient practice resulted in the inaccurate meal percentage documentation for Resident 7 and may result in the resident not receiving interventions for weight loss. Cross Reference F692 Findings: During a review of Resident 7's admission Record (AR), the facility admitted Resident 7 on 6/25/2025 with diagnoses that included protein-calorie malnutrition, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can use weight loss, decreased appetite, poor…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-19 · 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

    Based on interview and record review, the facility failed to accurately documentation for one of three residents (Resident 36)'s urine characteristics were in the Medical Administration Record (MAR) for October 2025 in accordance with the facility's policy and procedures (P&P) titled Documentation - Nursing, dated 01/01/2016. This deficient practice had the potential to result in inaccurate documentation in Resident 36's urine characteristics which may lead to a missed change of condition in Resident 36. Findings: During a review of Resident 36's admission Record (AR), the facility admitted Resident 36 on 2/4/2022 and readmitted Resident 36 on 6/1/2025 with diagnoses that included atrial fibrillation (AF, irregular and rapid heartbeat) and benign prostatic hyperplasia (BPH, non-cancerous enlargement of the prostate gland) with lower urinary tract symptoms. During a review of Resident 36's Order Summary, dated 6/10/2025, the order indicated Resident 36 received Eliquis (blood thinner) tablet 5 milligrams (mg, unit of mass) 1 tablet by mouth for chronic atrial fibrillation. During a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled 'Infection Prevention and Control Program, dated 12/1/2021 for three of three sampled residents (Resident 13, 23, and 35) by failing to ensure: 1.Ensure Resident 13's nasal cannula (NS, a flexible tube with two prongs that rest in the nostril to develop supplement oxygen) was changed weekly and did not have a label or a date the last time it was changed. 2.Ensure the Housekeeper 1 performed adequate hand hygiene when going in and out of Resident 23 room while performing environmental cleaning and when bringing dirty laundry to the laundry room. 3.Ensure the Infection Preventionist (IP) 1 performed adequate hand hygiene when entering and exiting Resident 35's room. These deficient practices had the potential to result in Resident 13's NC to harbor pathogens (bacteria and viruses that causes disease) and spread diseases that could result in infections to the residents, visitors and staffs 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 25 citations
  • Potential for harm · Dcited before2025-09-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report a Coronavirus 2019 (COVID-19, a contagious disease) outbreak (two or more linked cases of the same illness) to the California Department of Public Health (CDPH) in accordance with the facility's policy and procedure titled Communicable Diseases - Outbreak when the facility experienced a COVID-19 outbreak on 8/14/25. This deficient practice resulted in the facility failing to notify CDPH when an outbreak occurred and had the potential for the facility to underreport future outbreaks within the facility. A review of Resident 3's admission record indicated the Resident was originally admitted to the facility on [DATE], with a diagnosis of Poly-osteoarthritis (pain, swelling, and stiffness in the joints), heart disease (Problems with the heart, such as blocked arteries or heart damage) and hypertensive heart disease(Heart problems caused by long-term high blood pressure). A review of Resident 3's History and physical (H&P) dated 2/25/2025, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 immediately notify a licensed nurse and not move a resident after a fall on 8/19/2025 prior to a licensed nurse' assessment, in accordance with the facility's policy and procedure (P&P) titled, Response to Falls, for one out of three sampled residents (Resident 1) reviewed for falls. CNA 1 lifted Resident 1 from the floor and moved the resident back to bed. CNA 1 did not notify Licensed Vocational Nurse (LVN) 1 until after 20 minutes. These deficient practices had the potential for Resident 1 to suffer further discomfort and complications from the unwitnessed fall. On 8/19/2025, LVN 1 found Resident 1 shivering and shaking in pain after the fall with a swollen and discolored left foot. The result of an X-ray (imaging technology that creates images of people's body, including the bones, and is often used in diagnosis fractures), dated 8/19/2025, indicated that the resident had a left foot…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 removed her personal protective equipment (PPE, specialized equipment such as gown, gloves, and mask that minimize exposure to hazards that may cause illness) before leaving a designated isolation room. 2. Ensure CNA 2 used proper hand hygiene in between Resident 8 and Resident 3 ' s room. 3. Ensure Kitchen Assistant [KA] wore gloves when handling and preparing food/drink in the kitchen. 4. Family Visitor (FM) 2 observed walking into the facility and resident hallway without wearing a surgical mask. 5. Ensure Certified Nursing Assistant (CNA) 6 performed hand hygiene when touching Resident 24 ' s wheelchair and food tray for lunch. 6. Ensure CNA 7 donned personal protective equipment (PPE) when entering 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accommodate the needs of one of three sampled residents (Resident 1) with history of fall and a high risk for fall, in accordance with the facility ' s policy and procedure by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was within reach. This deficient practice had the potential for Resident 1 not to receive assistance especially during a fall or not receive immediate care with Activities of Daily Living (ADL) if unable to reach the call light. Findings: During a review of Resident 1's admission Record, indicated the facility originally admitted Resident 1 on 10/2/2023 and readmitted on [DATE] with diagnoses that included osteoporosis (a disease that causes bones to become weak and more likely to break), generalized muscle weakness, and history of falling. During a review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 10/2/2024,…

    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 · D2024-10-17 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet professional standards of practice for one of three sampled residents (Resident 1), who sustained an unknown injury, when Resident 1 was found with swelling on the left cheek from an unknown cause. The facility failed to conduct neurological assessments (series of tests that evaluate a patient's nervous system function) and develop a care plan. As a result of these deficient practices, Resident 1 had the potential to suffer further deterioration of health. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included metabolic encephalopathy (a change in how the brain works due to an underlying condition), Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and muscle weakness. A review of Resident 1 ' s History and Physical (H&P), dated 9/19/2024, indicated the resident did not have the capacity to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-06 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS, a federal mandated resident assessment tool) was accurate for one of two sampled residents (Resident 20): These deficient practices had the potential to result in Resident 20 not receiving appropriate treatment and/or services. Findings: 1. A review of Resident 20 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was admitted to the facility on [DATE] with diagnoses that included Depression, chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) with acute (sudden ) exacerbation and chronic congestive heart failure (a condition where the heart has difficulty pumping blood thought out the body). A review of Resident 20 ' s History and Physical assessment dated [DATE], indicated Resident 20 did not have the capacity to understand and make decisions. A review of Resident 20 ' s MDS…

    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 before2024-10-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide 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 2. A review of Resident 20's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficult in breathing) with acute (sudden ) exacerbation and chronic congestive heart failure (a condition where the heart has difficulty pumping blood thought out the body). A review of Resident 20's History and Physical assessment dated [DATE], indicated Resident 20 did not have the capacity to understand and make decisions. A review of Resident 20's Order Summary Report indicated the following: a. On 5/06/2024, a physician order was made to change oxygen tubing weekly, every Sunday for oxygen use and as needed. b. On 3/26/2024, a physician order was made to administer Oxygen at 2 Liters (L- unit of measurement) per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-06 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure three out five Licensed Vocation Nurses (LVN ' s 2, 4, 5) in the facility completed their annual competency assessment and evaluation(a process that assess and evaluates an employees skills, knowledge and performance) for the appropriate job category, in accordance with the facility's Facility Assessment (facility assessment to determine what resources and services are necessary to care for its residents). This deficient practice placed the residents at risk for not receiving appropriate services, treatments, and risk for infection from daily care. Findings: A review of LVN's 2 employee file records indicated the facility hired LVN 2 on 9/19/2023. LVN 2's employee records included a LVN/RN Orientation & Annual Evaluation Skills Check List the form was signed by the employee and the DON, the instructions on the form indicated Employee name and a line for reviewed by Directions: check the number that best describes your experience with that particular skill, Self-Evaluation list of skills. A review of LVN's 4 employee…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-06 · 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 follow proper sanitation and safe food handling based on the facilities policy and procedure by failing to ensure: 1. A plastic container containing sugar was labeled with visible dates 2. A Styrofoam cup containing Baba ghanoush in the refrigerator was dated and labeled. These deficient practices had the potential to place residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: On 10/07/2024 at 7:10 PM, during an initial observation of the kitchen, a round plastic container containing sugar inside was observed in the dry goods storage area. The container had a label on the outside with 3 different dates observed indicating 11/14/2022, 11/20/2022, and 5/18/2. There was no indication indicating the received date, opened date, or expiration date. During an observation on 10/07/2024 at 7:30 PM a white, Styrofoam cup in the refrigerator containing a light-yellow thick substance covered with clear plastic. There was no label indicating…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-06 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the physician of a significant change of condition in accordance with the plan of care and the facility's policy and procedure for one of three sampled residents (Resident 23) with severe weight loss (involuntary loss of 10% or more of usual body weight within 6 months) of 10.13% in three months. As a result of this deficient practice Resident 23 received delayed necessary care and intervention to maintain and prevent further weight loss that could lead to a decline in the resident's well being. Findings: A review of Resident 23's Face Sheet (front page of the chart that contains a summary of basic information about the resident), indicated the resident was readmitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), acute respiratory failure with hypoxia (a condition where you don ' t have enough oxygen…

    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 before2024-10-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and evaluate and determine the cause of severe weight loss in accordance with the facility ' s policy and procedure for one of one three sampled residents (Resident 23) who had an unplanned severe weight loss of 10.13% in three months by failing to: 1. Ensure to report the severe weigh loss to the physician from July to August 2024 to determine the cause of weight loss related to resident ' s disease process 2. Ensure the licensed staff consult with the dietician assessment and for any new dietary recommendations. 3. Develop a care plan for Resident 23 ' s severe weight loss in August 2024 (13 lbs.) These deficient practices resulted in not identifying and addressing severe weight loss, the interdisciplinary team was not able to assess and address underlying causes and the need for interventions to minimize any subsequent complications. Findings: A review of Resident 23 ' s Face Sheet (front page of the chart that contains a summary of basic…

    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 before2024-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide sufficient monitoring and supervision to one of three sampled residents (Resident 1) who had an unwitnessed fall on 4/11/24. This deficient practice resulted to a laceration on the head and above the right eye of Resident 1 that needed medical attention. Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 9/22/23 with diagnoses including congestive heart failure (a long-term condition in which the heart could not pump blood well enough to meet the body's needs). A review of Resident 1 ' s History and Physical assessment, dated 9/23/23, indicated that the resident did not have the capacity to understand and make decisions for herself. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool), dated 3/27/24, indicated that the resident ' s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was severely impaired and the resident needed moderate to maximum…

    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 · D2024-04-29 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 assess the medical need for the use of a bed side rail for one of three sampled residents (Resident 1) that resulted to an unwitnessed fall. This deficient practice made Resident 1 suffer a laceration above her right eye and on her head that required medical attention. Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 9/22/23 with diagnoses including congestive heart failure (a long-term condition in which the heart could not pump blood well enough to meet the body's needs). A review of Resident 1 ' s History and Physical assessment, dated 9/23/23, indicated that the resident did not have the capacity to understand and make decisions for herself. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool), dated 3/27/24, indicated that the resident ' s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was severely impaired and the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-18 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2), received restorative nursing services (RNA -a program available in nursing homes that helps residents maintain any progress they've made during therapy treatments, enabling them to function at a high capacity) as indicated in the physician order. As a result, Residents 1 did not receive RNA services on the following dates: 1. Resident 1 on 2/27/2024, 2/28/2024, and 2/29/2024, from 3/01/2024 to 3/18/2024. 2. Resident 2 on 2/21/2024, 2/22/2024, 2/23/2024, and 2/24/2024, 2/27/2024, 2/28/2024, and 2/29/2024, 3/01/2024 to 3/18/2024. This deficient practice had the potential to place Residents 1 and 2 at risk for further decline in range of motion (ROM) and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: 1. A review of Resident 1's admission Record indicated the resident was admitted to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-08 · tag F0656 — failed to write and follow a full care plan — pattern
    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 an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for two of 12 sampled residents (Residents 90 and Resident 1) by failing to: 1a. Develop an individualized/person-centered care plan with goals and interventions for Resident 90 with diagnosis of dementia (a brain disorder that results in memory loss and personality changes that affects the daily life). 1b. Develop an individualized/person-centered care plan with goals and interventions for Resident 90 who was receiving oxygen therapy. 2. Develop an individualized/person-centered care plan for Resident 1 who was receiving Aspirin (a medication that prevents blood clot to form). These deficient practices had the potential for the residents to not receive appropriate care treatment and/or services. Findings: 1a. During a review of Resident 90's admission Record indicated Resident 90 was admitted to 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide 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 administer oxygen therapy (treatment that provides supplemental, or extra, oxygen) according to physician's order and in accordance the facility's policy and procedure for two of two sampled residents (Resident 30 and 90). The facility failed to ensure: 1. Resident 30 was observed with the nasal cannula (NC, a plastic tube used to deliver oxygen to the nare) tubing was on the floor at the bedside. 2. Resident 90's was observed with the NC placed in resident's left nostril and none in the right nostril (one prong of the nasal cannula placed in the left nostril and the other prong was right open to air). This deficient practice placed Resident 30 and 90 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which can lead into serious injury or death. Findings: 1. A review of Resident 30's Face Sheet (a document that gives a patient's information at a quick glance) indicated the resident was readmitted 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 · Ecited before2023-10-08 · 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 store, prepare, distribute and serve food in accordance with professional standards of practice and it's policy and procedure on food service safety, proper sanitation and food handling practices by failing to: 1. Ensure the kitchen Aide (KA 1) 1 was wearing a hair net while washing the dishes in the facility's kitchen. 2. Ensure that food items stored in the refrigerator were dated when it was first opened. These deficient practices had the potential for residents to be at risk for contracting food borne illnesses (infections or irritations of the gastrointestinal tract caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals). Findings: 1. During an initial tour of the kitchen on 10/6/2023 at 6:32 p.m., KA 1 was observed not wearing a hairnet or hair cover while washing the dishes. KA 1 stated, she forgot to wear the hairnet while in the kitchen. KA 1 stated it was important to wear a hairnet to prevent hair from falling into the food or kitchen utensils in the food…

    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 · Ecited before2023-10-08 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary environment to help prevent the spread and transmission of infections for three of three residents ( Residdent 30, 22 and 90) in accordance with the facility's policy and procedure by failing to: 1. Ensure that nasal cannula or oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was not touching the floor for Resident 30. 2. Ensure that Certified Nursing Assistant (CNA) 1 don (put on) personal protective equipment (PPE such as gown, gloves, mask, face shield) before entering Resident 22's room with contact isolation precautions (infectious agents, including epidemiologically important microorganisms which are spread by direct or indirect contact with the patient or the patient's environment) signage. 3. Ensure that CNA 1 and CNA 2 doff PPE near designated trash bin for soiled PPE. 4. Ensure trash bin for soiled PPE is located inside…

    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 · Dcited before2023-10-08 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide reasonable accommodation of need for one of one sampled resident (Resident 33) who was at risk for fall. The facility failed to ensure the Resident 33's call light was within reach as indicated in the facility's policy and procedure, titled Communication and resident's care plan. This deficient practice had the potential for the resident not to receive necessary care and services, or receive delayed care to in an event of an emergeny that could result in fall and accident. Findings: During a review of Resident 33's admission Record, indicated the facility admitted Resident 33 on 3/30/2023 with diagnoses that included abnormalities of gait (a person's manner of walking ) and mobility, hypertension (high blood pressure), and osteoarthritis(degenerative joint disease). During a review of Resident 33's History and Physical (H&P), dated 3/31/2023, the record indicated, Resident 33's did not have the capacity to understand and made decisions. During a review of Resident 33's care plan titled, Fall Care Plan,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-08 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 act upon the consultant pharmacist's recommendation to obatain a blood draw of a basic metabolic panel (BMP- blood test that check the body's fluid balance and levels of electrolytes [minerals that carry an electric charge] evaluate the need of potassium (an electrolyte) supplement for one of five sampled resident (Resident 35). This deficient practice had the potential for Resident 35 to have abnormal body and heart function due to the abnormal laboratory test due to the licensed staff's failure to act upon the reported irregularities by the pharmacist. Findings: During a review of Resident 35's admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), muscle weakness, and hypertension (high blood pressure). During a review of Resident 35's History and Physical (H&P), dated 8/9/2023, the record 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-11-19 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to post an accurate nurse staffing information of actual hours worked by Registered Nurses (RN), License Vocational Nurse (LVN) and Certified Nurse Aides (CNA) per shift on 9/1/2025 up to 9/28/2025 in accordance with the facility's policy and procedure titled Nursing Department - Staffing, Scheduling & Posting. This deficient practice of posting inaccurate nurse staffing information mislead information provided to the residents, resident's responsible parties and visitors about the nursing staffing for the residents. Findings: During a review of the facility documents titled Daily Staff Record, (posting of staffing information) dated 9/1/2025 up to 9/28/2025, the document indicated, the number of scheduled licensed staff and CNAs per shift (not specific to actual hours worked by the nursing staff). During a concurrent interview and record review of Daily Staff Record, on 9/30/2025, at 10:35 AM, with Director of Nurses (DON) indicated on 9/1/2025 to 9/28/2025 the number of scheduled licensed staff and CNAs per shift reflected…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-11-19 · tag F0911 — pattern
    Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
    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 resident's bedrooms accommodated no more than four residents for four (4) of 12 rooms (rooms [ROOM NUMBERS] with six beds in the room, and rooms [ROOM NUMBERS] with five beds in the room) in the facility in accordance with the facility's policies and procedures (P&P) titled Resident Rooms and Environment, dated 11/1/2017. This deficient practice had the potential to negatively affect the residents' privacy, safety, and quality of care due to inadequate space for quality nursing and emergency care services. Findings: During a review of the facility's request for an additional room waiver, dated 11/19/2025, the room waiver indicated rooms [ROOM NUMBERS] were designated for five (5) beds per room and indicated rooms [ROOM NUMBERS] were designated for six (6) beds per room. The room waiver indicated there was adequate space for residents to be transferred out via wheelchair, had adequate range of motion, and accessibility. 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-11-19 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 resident's bedrooms measured at least 80 square feet per resident in four (4) of 12 rooms (Rooms 1, 3, 4, and 5) in the facility in accordance with the facility's policies and procedures (P&P) titled Resident Rooms and Environment, dated 11/1/2017. This deficient practice had the potential to negatively impact the care and services of the facility's staff to provide safe nursing care and privacy to the residents. Findings: During a review of the facility's request for an additional room waiver, dated 11/19/2025, the room waiver indicated rooms [ROOM NUMBERS] were approximately 456 square feet (sq. ft) and rooms [ROOM NUMBERS] were approximately 348 sq. ft. The room waiver indicated that the delivery and quality of care would not be impacted by the room size, and there was enough space for all residents, both for ambulatory (walking) and non-ambulatory residents. The room waiver indicated the residents in Rooms 1, 3, 4, and 5…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2024-10-06 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for four out of twelve resident rooms (Rooms 1, 3, 4, 5). The 4 resident rooms consisted of 2 (two) -six (6) bed capacity rooms and 2 -five (5) bed capacity rooms. This deficient practice had the potential to impact the care and services of the facility staffs to provide safe nursing care and privacy to the residents. Findings: During an interview with the Administrator (ADM) on 10/5/2024 at 12:10 PM, the ADM stated the facility would like to request for a room waiver this year. The ADM stated nothing was changed and the number of bed occupancy in rooms 1, 3, 4, and 5 remained the same. A review of the Client Accommodations Analysis form dated 10/5/2024, indicated the facility had 4 rooms (room [ROOM NUMBER], 3, 4, and 5) that did not meet the federal requirements with more than 4 residents and measured less than the required 80 square feet per bed. 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2023-10-08 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft. unit of measurement) per resident for four of twelve resident rooms (Rooms 1, 3, 4, 5). The 4 resident rooms consisted of 2 (two) six (6) bed capacity rooms and 2 five (5) bed capacity rooms. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents. Findings: During an interview with the Administrator (ADM) on 10/7/2023 at 12:06 PM, the ADM stated the facility would like to request for a room waiver this year. The ADM stated nothing was changed and the number of bed occupancy in rooms 1, 3, 4, and 5 remained the same. A review of the Client Accommodations Analysis form dated 10/7/2023, indicated the facility had 4 rooms (Rooms 1, 3, 4, and 5) that did not meet the federal requirements with more than 4 residents and measured less than the required 80 square feet per bed. A review of the facility's request for additional room waiver…

    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.

    Environmental Deficiencies · Waiver has been granted

“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

$10,039 in federal fines across 1 penalty.

  • $10,039 — penalty dated 2024-11-07

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
ARARAT HOME OF LOS ANGELES INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 05/30/1980
DARAKJIAN, PETERIndividualCORPORATE DIRECTORsince 04/01/2010
GHOOKASIAN, DERIKIndividualCORPORATE DIRECTORsince 11/28/2015
KANIMIAN, JOSEPHIndividualCORPORATE DIRECTORsince 04/01/2008
SINANIAN, SINANIndividualCORPORATE DIRECTORsince 04/07/2022
TAYLOR, ROBERTIndividualCORPORATE DIRECTORsince 08/24/2023
HMAYAKYAN, SAMVELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2013
KESHISHYAN, VARSENIKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2024

CMS files one row per role, so the 11 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$5.2M
Net patient revenuemost recent cost report
+6.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 83%Medicare 17%Other / private 0%

About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

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

$403per resident / day
operating cost
$12,263per month
≈ monthly operating cost
$431per 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 555126. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-19, 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