Burlington Convalescent Hospital
845 S.burlington Avenue, Los Angeles, CA 90057 · For profit - Corporation · 124 certified beds · (213) 381-5585 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,278 in federal fines (most recent 2025-02-21)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.8% | 10.2% | 15.4% | typical |
| Long-stay residents who lose too much weight | 6.4% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.6% | 1.2% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 7.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.8% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 14.6% | 9.8% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 1.4% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.5% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 6.8% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.5% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 69.0% | 93.2% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 21.7% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 1.1% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.49 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.96 | 1.57 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
27.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 41.9% 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 74 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 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 27.0%CMS range 19.2–36.2 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 7.1–13.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 41.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 39.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 51.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 2.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.2%CMS range 3.4–9.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 124 beds and averages 116.2 residents a day — about 94% occupied, or roughly 8 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 4.01 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.71 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.72 hrs/resident/day on weekends vs 4.13 on weekdays — 10% thinner on weekends. RN hours go from 0.50 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · Gcited before2025-02-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise/update fall care plan to include updated interventions after the fall on 12/28/2024 to prevent a repeat fall for one of two residents (Resident 165) who was a high risk for fall. As a result, on 2/3/25, Resident 165 fell again and suffered severe pain of 7 (seven) out of 10 (7/10 - a numerical pain scale assessment tool where zero is no pain and 10 is severe pain) to the buttocks and to the left and right thighs. On 2/5/2025, the facility transferred Resident 165 to General Acute Care Hospital (GACH) 1 via non-emergency medical transportation where Resident 165 was diagnosed with a left hip fracture (broken bone). On 2/16/25, GACH 1 performed an open reduction and internal fixation (ORIF - a type of surgery used to stabilize and repair broken bones, using screws, plates, sutures, or rods to hold the bone together and for healing) on Resident 165. Findings: During a record review, Resident 165's admission Record indicated the facility admitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-21 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 observation, interview, and record review, the facility failed to notify the physician regarding a significant change in condition for one of three sampled residents (Resident 1), who refused to continue dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to) treatment and verbalized a desire to die.This failure resulted in delayed physician evaluation, psychiatric intervention, and implementation of medically necessary treatment and safety measures.During a review of Resident 1's admission Record, dated 5/21/2026 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life) requiring dialysis and depression (a mood disorder that may cause persistent sadness or loss of interest in activities).During a review of Resident 1's Minimum…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for one of three sampled residents (Resident 1) to address diagnosis of depression (a mood disorder that may cause persistent sadness or loss of interest in activities), refusal of treatment, and non-pharmacological interventions for mood and behavioral symptoms.This failure had the potential to place the resident at risk for worsening depression, psychosocial decline, nutritional compromise, and lack of appropriate mental health interventions.During a review of Resident 1's admission Record, dated 5/21/2026 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life) requiring dialysis and depression.During a review of Resident 1's Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary care and services for one of three residents (Resident 1) by failing to obtain timely psychiatric evaluation and intervention for Resident 1 exhibiting depression (a mood disorder that may cause persistent sadness or loss of interest in activities), refusal of dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to), and verbalizations indicating a desire to die.This failure placed Resident 1 at risk for worsening mental health status, self-neglect, decline in medical condition, and avoidable harm.During a review of Resident 1's admission Record, dated 5/21/2026 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life) requiring dialysis and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-14 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure kitchen staff labeled all foods stored in the refrigerator and freezer with the correct food name, date of food delivery, date the food container was opened, and best by date. This deficient practice of not correctly labeling all foods stored in the refrigerator and freezer had the potential for residents who consume food from the kitchen to suffer from foodborne illnesses (refer to illnesses such as nausea, vomiting, and diarrhea, caused by the ingestion of contaminated food or beverages) and hospitalization Findings: During an observation in the kitchen on 5/11/2026 at 7:55 AM, several food items and drinks in the refrigerator and freezer were not labeled as follows:Iceberg lettuceClear drinks (appeared to be water)CilantroFrozen food in red color in dessert cups (unable to identify what it is)White colored drinks (appeared to be milk). During a concurrent observation and interview on 5/11/2026 at 8:12 AM with the Dietary Services Supervisor (DSS - manages daily food service operations, ensuring safe, nutritious,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-14 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that two out of two residents (Resident 5 and Resident 45) did not sign Advanced Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). Resident 5 and Resident 45 had severe cognitive (the mental ability to make decisions of daily living) impairment. This deficient practice violated Resident 5 and Resident 45's rights with the potential to cause conflict with the residents healthcare wishes.Findings: During a review of Resident 5's admission Record, the admission record indicated the facility admitted the resident on 1/10/2018 with diagnoses that included but not limited to cerebral infarction (loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 securely store and dispose off personal health identifiable (PHI - any health-related data that can directly or indirectly trace back to a specific individual) information was stored securely and disposed after admission from a general acute care hospital (GACH) visit for one of one (Resident 129). The deficient practice had the potential to result in a breach protected PHI and medical identity theft, targeted financial fraud, and alterations to personal medical records for Resident 129's. Findings: A review of Resident 129's admission record indicated Resident 129 was admitted to the facility on [DATE], with diagnoses that include end stage renal disease (severe phase of kidney (organ that filters bodily waste) disease where your kidneys permanently lose about 85 percent (%- unit of measurement) to 90% of their function, leaving them unable to filter waste and excess fluid from the blood), fracture (crack or break in one of the bones) of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 maintain a clean, sanitary, and homelike environment for one out of one resident (Resident 110). This deficient practice had the potential for Resident 110 to experience low self esteem and not appreciated. Findings: During a review of Resident 110's admission Record, the admission record indicated the facility admitted the resident on 3/25/2026 with diagnoses that included but not limited to schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 110's Minimum Data Set (MDS - a resident assessment tool) dated 3/5/2026, the MDS indicated Resident 110 had moderate cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 110 needed partial/moderate staff assistance with activities of daily living (ADL- including upper body assist and personal hygiene, set up/cleaning assistance for eating and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure facility staff provided an accurate medical concern description to an optometrist (OPT - a primary healthcare professional who specializes in eye and vision care) when Resident 101's eyeglasses were missing for of one of four residents' (Resident 101) . This deficient practice resulted in Resident 101 complaining that without his eyeglasses, his eyes would get wet, it was very hard to see or do anything, he could not read and loves to read. Findings: During a review of Resident 101's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 101 was admitted to the facility on [DATE] with the following diagnoses: hypercapnia (a condition where there is an abnormally high level of carbon dioxide in the bloodstream), hypercalcemia (a condition where the calcium level in your blood is abnormally high that can lead to weakened bones, kidney stones, and severe heart or neurological complications if…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to supervise and monitor and immediately attend to residents' meal carts to ensure that one of one sample resident (Resident 54) did not access meal carts that had left over foods and drinks. Resident 54 has a history of dysphagia (difficulty swallowing). This deficient practice placed Resident 54 at increased risk for aspiration (accidentally inhaling food or liquids which can lead to infection), hospitalization, and death.Findings: During a review of Resident 54's admission Record, the admission record indicated the facility admitted the resident on 3/2/2026 with diagnoses that included but not limited to severe protein-calorie malnutrition (potentially life-threatening condition caused by an inadequate intake of protein, calories and other macronutrients) and dysphagia.During a review of Resident 54's Minimum Data Set (MDS-a resident assessment tool) dated 4/2/2026, the MDS indicated Resident 54 had moderate cognitive impairment. The MDS indicated Resident 54 needed partial/moderate assistance for activities of daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to remove expired medication prescribed for two out of eight sampled residents (Resident 6 and Resident 64) from the medication cart (is a mobile workstation used in healthcare facilities to store, transport, and dispense medicines, medical equipment, and supplies). This deficient practice had the potential to result in the administration of expired medications to residentsFindings: A review of Resident 6's admission record indicated Resident 6 was admitted to the facility on [DATE], with medical diagnoses that included: Hypertension (high or raised blood pressure), Acute Kidney Failure (a condition in which the kidneys suddenly can't filter waste from the blood), and Depression (a constant feeling of sadness and loss of interest). A review of Resident 6's Minimum Data Set (MDS - a resident screening tool) dated 4/23/2026, indicated Resident 6's cognition (the mental action or process of acquiring knowledge and understanding through thought,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · D2026-05-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for two of two sampled residents (Resident 4 and Resident 54) the facility failed to:1. Ensure staff provide Resident 4 with a clean urinal (a portable, reusable or disposable container into which a resident can urinate without getting out of bed) This deficient practice placed Resident 4 at increased risk for infections due to contamination (unintentional transfer of bacteria/germs or other contaminants from urinal to the resident).2. Ensure Resident 54 did not have access to meal carts with left over foods and drinks already consumed by residents. This deficient practice placed Resident 54 at increased risk to suffer from food borne illness/ infections due to contaminated (unintentional transfer of bacteria/germs or other contaminants from urinal to the resident) food and drinks Findings: 1. During a review of Resident 4's admission Record, the admission record indicated the facility admitted the resident on 3/25/2026 with diagnoses that included but not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interview, the facility failed to maintain an insect free building according to its facility's policy and procedures (P&P) titled Pest Control with review date 3/17/2026, for one of one sampled resident room (Resident 14). This deficient practice had the potential to significantly compromise the resident's safety, health leading to infection and possibly hospitalization.Findings: A review of Resident 14's admission Record indicated the facility admitted Resident 14 on 4/7/2026 with diagnoses including hypertension (HTN-high blood pressure) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and anemia (a condition where the body does not have enough healthy red blood cells). A review of Resident 14's Minimum Data Set (MDS - a resident assessment tool) dated 4/14/2026, indicated Resident 14 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 14 was dependent on staff with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-12 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to maintain record that is complete and accurate for one of three sampled residents (Resident 1). For Resident 1 the facility failed to: 1.Provide assistance with activities of daily living (ADLs) on 11/11/22. 2.Document nursing services that were provided to Resident 1 on 11/11/22 from 7 p.m. to 12:30 a.m. These deficient practices resulted in incomplete and inaccurate medical record for Resident 1. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 11/11/22 with diagnoses including respiratory failure (impaired gas exchange between the lungs (breathing organ) and the blood) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1's admission Assessment indicated the facility admitted Resident 1 on 11/11/22 at 7 p.m. The Assessment indicated Resident 1 was confused. Resident 1 was dependent with eating/nutrition, personal hygiene and grooming. Resident 1 was incontinent of bowel and bladder. During a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-21 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 residents received meals with flavor, attractive, appetizing, nutritive value, proper temperature, safe, and adequate portions. This deficient practice had the potential for the residents to experience poor/reduced meal intake, weight loss, and a decline in their health status. Findings: a. During a record review, the Resident Council Meeting minutes 11/13/2024 at 2 PM, a resident complained that the, Rice is not cook enough and can't digest it. During Resident Council Meeting on 2/19/2025 at 10:50 AM, four residents (Residents 40, 45, 62, and 65) were present. Resident 62 stated the facility give so little food and we eat cold soup. Resident 40 stated, the sandwich has cheese, and no meat. Resident 65 stated the sandwich has two breads and a cheese, no meat, nothing more. I didn't like the food. The food is not enough. Resident 45 stated that, the food food was cold when it's supposed to be hot. During record review, the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-21 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to ensure that: 1. Kitchen staff are trained and competent in food cooling down method 2. Cooked left over chicken and ground beef are not stored in the refrigerator 3. Kitchen staff recorded and retained documented evidence of the cooling down food/meat following the cooling down method. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins) medically compromised residents who received food from the kitchen. Findings: During the initial tour and observation of the kitchen on 02/18/2025 at 7:29 am, with Tray line staff, the kitchen refrigerator had a container of cooked chicken and ground beef. During a concurrent interview, the Tray line staff he stated the cooks are not supposed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-21 · tag F0813 — patternHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and record review, the facility failed to provide a refrigerator to store food brought in for the residents. This deficient practice had the potential to cause food borne illness due to the residents not having a refrigerator to store their food. Findings: During record review, the Facility Listing Report dated 2/18/2025, indicated the resident census was 111. During an observation and interview on 2/20/25 02:41 pm with the Registered Dietician, the Registered Dietician stated that the facility does not have a refrigerator for the residents to store food brought in from outside the facility. Registered Dietician stated she recommends that the residents and the residents family members to not bring in food that needs refrigeration. Registered Dietician stated it is the residents right to have food bought in by their families. During record review, the facility policy and procedures titled Food From Outside Sources indicated, Policy: Food brought to the facility by visitors and family is permitted.
- Potential for harm · D2025-02-21 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility's interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to ensure that a resident would not be allowed to keep medications at the bedside without a physician's order and/or without being assessed to determine if the resident is capable to self-administer medications for one of 12 sampled residents (Resident 58). This deficient practice had the potential for other residents to gain access/ingest the medication and or result in adverse reaction to the medication. Findings: During record review, Resident 58's admission record indicated Resident 58 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation (an irregular and often very rapid heart rhythm), hypertension (a medical condition characterized by persistently elevated blood pressure), encephalopathy (a change in your brain function due to injury or disease),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-21 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to complete a change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) in accordance with the facility's policy and procedures (P&P) titled Change in a Residents Condition or status revised 3/2023 for one of four sampled residents (Resident 39). This deficient practice had the potential to result in the delay of care for Resident 39. Findings: During record review, Resident 39's admission Record indicated the facility admitted Resident 39 on 6/12/2024 and readmitted Resident 39 on 9/9/2024 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure). During record review Resident 39's Weight Summary indicated the following weights: 10/29/2024 : 105.0 pounds (lbs -unit of measure)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop a baseline care plan in accordance with the facility's policy and procedures (P&P) titled Care plans, Comprehensive Person-Centered revised 3/2023 for one of four sampled residents (Resident 39). These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 39. Findings: During record review, Resident 39's admission Record indicated the facility admitted Resident 39 on 6/12/2024 and readmitted Resident 39 0n 9/9/2024 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure). During record review, Resident 39's Minimum Data Set (MDS - a resident assessment tool) dated 12/16/2024, indicated Resident 39 was cognitively intact (when a person has no trouble remembering, learning new…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide activities of daily living (ADL-such as bathing, showering, toileting, and mobility) for one of four residents (Residents 14) This failure had the potential to result in Resident 14 acquiring infection, and foul odor of the feet. Findings: During record review, Resident 14's admission Record indicated the resident was re-admitted to the facility on [DATE] with diagnoses not limited to hemiplegia (complete paralysis on one side of the body), hemiparesis (weakness or reduced movement on one side of the body), and anemia (a condition in which the body does not have enough healthy red blood cells). During record review, resident 96's Minimum Data Set (MDS- a resident assessment tool) dated 11/25/24, indicated Resident 14's cognitive skills- (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making was not intact. The MDS further indicated Resident 14 needed extensive assistance with ADL's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-21 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that staff did not crush Ferrous Sulfate (supplement) Oral (by mouth) tablet 325 (65 Fe) mg 1 tablet by mouth and administered via gastrointestinal tube (G-tube -feeding tube surgically inserted into the stomach). for one of four sampled residents (Resident 315). This deficient practice: 1. Resulted in staff crushing and administering Ferrous Sulfate Oral tablet 325 mg 1 tablet via GT for six days. 2. Had the potential to result in increasing the risks of side effects, toxic effects and/or hospitalization. Findings: During record review, Resident 315's admission Record indicated the facility admitted Resident 315 on 6/9/2023, and readmitted Resident 315 on 2/12/2025 with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and adult failure to thrive (a noticeable decline in health). During record review, the physician's orders dated 2/12/2025 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-21 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, facility failed to accurately and completely document medication administration in the resident's chart for one of four sampled residents (Resident 39). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 39. Findings: During record review, Resident 39's admission Record indicated the facility admitted Resident 39 on 6/12/2024 and readmitted Resident 39 on 9/9/2024 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure). During record review, Resident 39's Minimum Data Set (MDS - a resident assessment tool) dated 12/16/2024, indicated Resident 39 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-09 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably 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 ensure that call buttons were within reach for two of 26 sampled residents (Resident 1 and Resident 11). This deficient practice had the potential for the residents' needs not being met, placing the residents at risk for accidents including falls and injuries. Findings: 1. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with medical diagnoses that included hemiplegia (one sided muscle paralysis or weakness), dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), and ataxia (poor muscle control that causes clumsy movements). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/18/2024, indicated Resident 1 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and was dependent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-09 · tag F0639 — patternMaintain 15 months of resident assessments in the resident's active clinical record.
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, facility failed to obtain and retain all resident assessment for hospice (care that is focused on the comfort and quality of life for a person with a serious illness who is approaching the end of life) care in residents active record for one of three sampled residents (Resident 44). This deficient practice had the potential for the resident not receiving needed care according to assessment and care plans. Findings: Cross Reference F849 A review of Resident 44's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses that included dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), cervical spinal cord injury (affecting the head, neck region above the shoulder), and diabetes mellitus (DM- a metabolic disease, involving inappropriately elevated blood glucose[sugar] levels). A review of Resident 44's Minimum Data Set (MDS - a standardized…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-09 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and food thawing practices in the kitchen when: a. Thawing pork at room temperature. b. One of five staff did not wear gloves during Trayline food preparation. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of bacteria from one object to another) that could lead to foodborne illness in medically compromised residents who received food from the kitchen. Findings: a. During the initial kitchen tour observation of the food preparation sink on 2/6/2024 at 7:38 A.M., pork ribs in a food container and chopped pork in food storage bags were thawing in the food preparation sink at room temperature. During an interview on 2/6/2024 at 7:48 A.M., [NAME] 1 stated the meat was pork and [NAME] 1 was preparing to cook the meat for lunch. [NAME] 1 stated that the meat should be thawed under running water. b. During observation of the Trayline food preparation on 2/7/2024 at 12:10 A.M., Dietary Aide 1 (DA1) did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-09 · tag F0849 — patternArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to obtain and retain all resident assessment for hospice (care that is focused on the comfort and quality of life for a person with a serious illness who is approaching the end of life) care in residents active record for one of three sampled residents (Resident 44). This deficient practice had the potential for the resident not receiving needed care according to assessment and care plans. Findings: Cross Reference F639 A review of Resident 44's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses that included dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), cervical spinal cord injury (affecting the head, neck region above the shoulder), and diabetes mellitus (DM- a metabolic disease, involving inappropriately elevated blood glucose[sugar] levels). A review of Resident 44's Minimum Data Set (MDS - a standardized…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-09 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
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 maintain the handwashing sink for kitchen area in a safe operating condition. This deficient practice had the potential for kitchen staff not being able to perform hand washing which was required for staff before starting work in the kitchen and before and after handling foods. Findings: During the initial kitchen tour on 2/6/2024 at 7:38 A.M., at the entrance to the kitchen area, Dietary Supervisor (DS) stated the cold-water faucet at the handwashing sink had been leaking for over two weeks. During an observation on 02/07/24 at 11:45 A.M., handwashing sink at the entrance to the kitchen area had leaking cold water. The hot water measured by the DS was 135.7 Fahrenheit (F) & 136.2 F degrees after 3 minutes of running the hot water. During an interview with dietary supervisor (DS) on 2/7/2024 at 11:45 A.M., the DS stated the cold-water faucet had been broken for over two weeks. The DS stated that she notified the maintenance supervisor (MS) about the problem two weeks ago. During an interview with the MS on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-09 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based interview, and record review, the facility failed to ensure that advanced healthcare directives (legal documents that outline an individual's preferences regarding major medical decision) information was provided to the resident representative (RP) for one of eight sampled residents (Resident 11). This deficient practice had a potential to violate the resident's rights related to the provision of health care. Findings: A review of Resident 11's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses that included dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), diabetes mellitus (DM- a metabolic disease, involving inappropriately elevated blood glucose[sugar] levels), and hypertension (HTN -elevated blood pressure). A review of Resident 11's History and Physical (H&P-a comprehensive formal assessment by a physician), dated 7/17/2023, indicated Resident 11 did not have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the residents ' environment remained free of accident hazards for one of three residents (Resident 1) by failing to ensure that a box of hand rubber gloves was not left within reach of a resident with a dementia (a decline in thinking skills). On 12/13/2023, Resident 1 developed acute (severe) sudden shortness of breath. This deficient practice resulted in Resident 1 was transferred to the General Acute Care Hospital (GACH 1) and during endotracheal intubation (a medical procedure in which a tube is placed into the windpipe through the mouth or nose) a rubber glove was found intraorally and was removed. Findings: A review of Resident 1 ' s admission record indicated, facility admitted the resident on 12/12/2023 with diagnoses which included urinary tract infection (UTI-infection of the urinary tract), vascular dementia (a decline in thinking skills caused by reduced blood flow to the brain) type 2 diabetes (a condition that affects the way 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.
- No harm found · Bcited before2025-02-21 · tag F0912 — patternProvide 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
Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms for 39 of 45 resident room(rooms 3,5,6,7,8,9,10,12,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45). Rooms 3,5 and 6 had two beds inside the room. Rooms 8,9,10,12,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45 had three beds inside the room. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the staff, which could affect the quality of life and safety for the residents. Findings: During record review, the Request for Room Size Waiver letter submitted by the Administrator (ADM), dated 2/18/2025, indicated 39 resident rooms in the facility do not meet the requirement of at least 80 square feet per resident per federal regulation. The letter also indicated the resident beds are in accordance with the special needs of the residents and will not adversely affect…
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.
- No harm found · Bcited before2024-02-09 · tag F0912 — patternProvide 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
Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms for 39 of 45 resident room(rooms 3,5,6,7,8,9,10,12,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45). Rooms 3,5 and 6 had two beds inside the room. Rooms 8,9,10,12,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45 had three beds inside the room. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the staff, which could affect the quality of life and safety for the residents. Findings: A review of the Request for Room Size Waiver letter submitted by the Administrator (ADM), dated 2/6/2024, indicated 39 resident rooms in the facility do not meet the requirement of at least 80 square feet per resident per federal regulation. The letter also indicated the resident beds are in accordance with the special needs of the residents and will not adversely affect resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,278 in federal fines across 1 penalty.
- $8,278 — penalty dated 2025-02-21
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to LONGWOOD MANAGEMENT CORPORATION — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.2 | +1.8 vs chain |
| Health inspection | 4 of 5 | 2.1 | +1.9 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 4 of 5 | 3.3 | +0.7 vs chain |
The other 37 homes this chain runs (chain average 2.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LIBBY CARE CENTER LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/26/2000 |
| AARON FRIEDMAN GROUP A BUSINESS ASSETS TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 20% | since 06/30/2023 |
| IRA DAVID FRIEDMAN GROUP A BUSINESS ASSETS TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 20% | since 06/30/2023 |
| DEVORAH DANZIGER GROUP A BUSINESS ASSETS TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 06/30/2023 |
| ELKA KAPLAN GROUP A BUSINESS ASSETS TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 06/30/2023 |
| ESTHER HOFF GROUP A BUSINESS ASSETS TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 06/30/2023 |
| LIBBY FRIEDMAN LEHMANN GROUP A BUSINESS ASSETS TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 06/30/2023 |
| MORDECHAI NOTIS GROUP A BUSINESS ASSETS TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 06/30/2023 |
| RACHEL NOTIS GROUP A BUSINESS ASSETS TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 06/30/2023 |
| RUCHEL FRIEDMAN KLAVAN GROUP A BUSINESS ASSETS TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 06/30/2023 |
| SARAH DUNNER GROUP A BUSINESS ASSETS TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 06/30/2023 |
| YEHOSHUA NOTIS GROUP A BUSINESS ASSETS TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 06/30/2023 |
| YISROEL NOTIS GROUP A BUSINESS ASSETS TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 06/30/2023 |
| FRIEDMAN, IRA | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF | — | since 06/30/2023 |
| HUANG, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/29/2022 |
| KIM, DOEYOUNG | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/11/2019 |
| KLAVAN, JOSHUA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/16/1986 |
| MYUNG, VEDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2023 |
| FRIEDMAN, AARON | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | — | since 06/30/2023 |
| LEHMANN, LIBBY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/18/2025 |
| NOTIS, SHMUEL | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/18/2025 |
| KLAVAN, RACHEL | Individual | TRUSTEE OF THE SNF | — | since 06/30/2023 |
| BURLINGTON CONVALESCENT INVESTMENTS II, LP | Organization | ADP OF THE SNF | — | since 06/30/2023 |
| FRIEDMAN FAMILY TRUST | Organization | ADP OF THE SNF | — | since 09/18/2025 |
| IRA D FRIEDMAN 1991 TRUST | Organization | ADP OF THE SNF | — | since 09/18/2025 |
| LEHMANN FAMILY 1991 TRUST | Organization | ADP OF THE SNF | — | since 09/18/2025 |
| LONGWOOD MANAGEMENT LLC | Organization | ADP OF THE SNF | — | since 01/01/2023 |
| MID WILSHIRE CAPITAL MANAGEMENT GROUP, LLC | Organization | ADP OF THE SNF | — | since 09/18/2025 |
| THE KLAVAN FAMILY TRUST | Organization | ADP OF THE SNF | — | since 09/18/2025 |
| THE TZIPPY FRIEDMAN NOTIS 1990 TRUST | Organization | ADP OF THE SNF | — | since 09/18/2025 |
| PERVAIZ, ZAID | Individual | ADP OF THE SNF | — | since 01/01/2013 |
CMS files one row per role, so the 43 rows in the source record cover these 31 parties — each is shown once here with every role it holds. Nothing is omitted.
21 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 056326. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, 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.