Huntington Healthcare Center
4515 Huntington Drive South, Los Angeles, CA 90032 · For profit - Corporation · 99 certified beds · (323) 225-5991 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,635 in federal fines (most recent 2023-09-25)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
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) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 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 2 to 3 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 | 23.3% | 10.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.6% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 1.2% | 2.0% | better |
| 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 | 0.0% | 1.6% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 13.1% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 2.2% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 90.5% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.3% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 7.2% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 13.0% | 93.2% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 2.6% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 1.2% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.56 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.37 | 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.
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.
Met the expected recovery: 88.1% 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 101 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 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 85% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 7.8%CMS range 4.9–11.5 | 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 | 88.1% | 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 | 92.1% | 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 | 91.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 0.0% | 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 | not 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 discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 4.2–10.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.70 | 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 99 beds and averages 93.6 residents a day — about 95% 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 4.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.19 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.01 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 3.73 hrs/resident/day on weekends vs 4.16 on weekdays — 10% thinner on weekends. RN hours go from 0.21 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below the national median of 45%. 1 administrator has left in the past year.
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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Ecited before2026-04-17 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the right measuring device and the right ingredients were used in preparing the Consistent Carbohydrate Diet (CCHO, meal plan designed to manage blood sugar, especially for diabetes) and the low sodium (salt) food. This deficient practice had the potential to affect all the residents receiving CCHO and low sodium diets. This had the potential to result in elevated blood sugar levels for diabetic residents and fluid overload (clinical condition where excess fluid builds up in the body), edema (swelling), heart failure (chronic condition where heart muscle becomes weak or stiff to pump blood efficiently to meet the body's needs for oxygen), for residents with kidney diseases.Findings: During a concurrent observation on 4/15/2026 at 11:50 a.m., with the Dietary Supervisor (DS), the DS observed and verified the kitchen staff used scooper #8 (kitchen utensil used to provide 4 ounces [oz, unit of measurement] or half [1/2] cup portions) to serve mashed potatoes. During a concurrent record review and interview…
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 · D2026-04-17 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure dental services were scheduled so that one of three sampled residents (Residents 1), was seen by a dentist (a health care professional who specializes in teeth, gums, and mouth).This deficient practice had the potential to result in the worsening condition of the resident's teeth, leading to tooth infection, to suffer toothache, affecting the resident's inability to eat. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included type 2 diabetes mellitus (chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar levels) and end-stage renal disease (ESRD, kidney failure). During a review of Resident 1's History and Physical (H&P) dated 12/17/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-17 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure 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 the food was palatable (tasty) for one of three sampled residents (Residents 1). This deficient practice had the potential for resident's poor meal intake and weight loss.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included type 2 diabetes mellitus (chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar levels) and end-stage renal disease (ESRD, kidney failure). During a review of Resident 1's History and Physical (H&P) dated 12/17/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/20/2026, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required maximal assistance (Helper…
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 · D2026-04-17 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 therapeutic diet (meal plan prescribed by a healthcare professional [physician or dietitian] that modifies a regular diet to manage a specific medical condition, treat an illness, or improve overall health) as ordered by the physician for one of three sample residents (Resident 1). This deficient practice resulted in high blood sugar readings for Resident 1 and had the potential to cause complications such as diabetic coma (life-threatening, state of unconsciousness caused by extreme blood sugar levels). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and end-stage renal disease (ESRD-irreversible kidney failure). During a review of Resident 1's History and Physical (H&P) dated 12/17/2025, the H&P 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.
- Potential for harm · Fcited before2025-12-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 preparation practices in the kitchen. This deficient practice had the potential to result in harmful bacterial growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 94 of 94 residents who received food from the kitchen. Findings:During an observation on 12/1/2025 at 8:15 a.m., in the kitchen, in the presence of the Dietary Supervisor (DS), the following findings were observed:a. The handwashing sink did not have hot water.b. The handwashing sink was clogged. c. The surface of the can opener was blackened and covered with black stains and dried residue.d. The area surrounding the can opener blade and gear were stained with dark, hardened food debris. e. The air-drying area for the food services equipment such as water pinchers, plates, cutting boards, cups and spoons was dusty and unsanitary. f. A large…
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 · D2025-12-04 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 a resident's personal inventory list was completed when staff did not obtain the resident's signature and did not document a valid reason for the missing signature for one of six sampled residents (Resident 3). This resulted in an incomplete inventory record and had the potential to affect the facility's ability to account for Resident 3's belongings.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), hypertension (high blood pressure), and diabetes (poor blood sugar control). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 10/16/2025, the MDS indicated Resident 3's cognitive skills (ability to think and reason) for daily decision…
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 · D2025-12-04 · tag F0641 — isolatedEnsure 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 complete accurate Minimum Data Set (MDS) assessments for four of 21 sampled residents (Residents 91, 61, 70 and 20) when failing to: 1. Ensure an accurate assessment of Resident 91's hearing and vision impairments.2. Ensure an accurate assessment of Resident 61 and 70's oral/dental status.3. Ensure an accurate assessment of Resident 20's hearing impairment. This failure had the potential to delay the development or the revision of care plan interventions for communication and sensory deficits for Resident 91 and 20, and dental status for Residents 61 and 70.Findings: 1. During a review of Resident 91's admission Record, the admission Record indicated Resident 91 was initially admitted to the facility on [DATE]. Resident 91's diagnoses included history of falling, functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), adult failure to thrive (a decline caused by chronic…
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 before2025-12-04 · 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 an individualized resident centered care plan for six of 18 sampled residents (Resident 91, Resident 20, Resident 42, Resident 55, Resident 61, and Resident 70) when: 1. Staff failed to develop a care plan addressing Residents 91 and 20's hearing impairment.2. Staff failed to develop a care plan addressing Resident 42 and 55's diagnosis of dementia (a progressive state of decline in mental abilities). 3. Staff failed to develop a care plan addressing Resident 61 and 70's missing natural teeth. These deficient practices had the potential for Residents 91, 20, 42, 55, 61, and 70 to not receive required appropriate care.Findings: 1. During a review of Resident 91's admission Record, the admission Record indicated Resident 91 was initially admitted to the facility on [DATE]. Resident 91's diagnoses included history of falling, functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord…
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 · D2025-12-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure good grooming and personal hygiene for two of six sampled residents (Resident 61 and Resident 5) by failing to provide routine fingernail and toenail care. This failure had the potential to result in a negative impact on Residents 61 and 5's quality of life and self-esteem and had the potential for the development of infections. Findings:a. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 61's diagnoses included dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), and major depression disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool), dated 6/28/2025, the MDS indicated Resident 61's cognition (ability to think and process information)…
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 · D2025-12-04 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate clinical records for one of five sampled resident (Resident 72) after a change in condition. This failure resulted in incomplete and missing documentation regarding Resident 72's clinical status and had the potential to affect the resident's continuity of care.Findings:During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 72's diagnoses included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (loss of memory, thinking, reasoning, and judgment), tachycardia (fast heart rate), hypertension (HTN - high blood pressure), pneumonia (infection in the lungs), hyperlipidemia (high fat levels in the blood), age-related physical disability (physical limitations related to aging), unspecified fall (a fall with no specific cause documented),…
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 16 citations
- Potential for harm · D2025-08-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the surgical face mask (a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment) of one of 4 staffs, was worn correctly while in a resident-care area, as indicated in the facility's policy and procedure (P&P) titled, Personal Protective Equipment-Using Face Masks.This failure had the potential to increase the spread of Coronavirus Disease 2019 ([COVID-19] highly contagious viral infection) virus to other residents, staff, and visitors in the facility, resulting in respiratory infections, hospitalizations and death.Findings:During a concurrent observation and interview on 8/18/2025 at 10:30 a.m. with Restorative Nurse Assistant (RNA 1) in Resident 2's room, RNA 1 was observed wearing surgical face mask below her nose with both nares (nasal openings) exposed. RNA 1 acknowledged the surgical face mask was applied incorrectly. RNA…
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 · E2024-10-18 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the fall care plan for one of nineteen sampled residents (Resident 64), following Resident 64's fall with subsequent injury on 6/20/2024. This deficient practice increased the potential for staff to be unaware of the interventions required to prevent Resident 64 from suffering additional avoidable falls and potential subsequent injuries. Findings: During a review of Resident 64's admission Record, the record indicated Resident 64 was admitted to the facility on [DATE]. Resident 64's admitting diagnoses included muscle wasting and atrophy (the loss of muscle tissue and strength), abnormalities of gait and mobility, weakness, and dementia (a progressive state of decline in mental abilities). During a review of Resident 64's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/23/2024, the MDS indicated Resident 64 had severely impaired cognition (problems with a person's ability to think, learn, remember, use judgement,…
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 · E2024-10-18 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1. Account for one dose of Controlled Substances (also known as Controlled Drug and Controlled Medications [CS, CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 23, in one of two inspected medication carts (Medication Cart 1.) 2. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with the Licensed Vocational Nurse (LVN) on the Controlled Drug accountability logs for six of six sampled records awaiting disposal (removal, destroying) in the DON's office. 3. Include the witness signatures and quantity on the Medication Disposition log for 16 non-CMs disposed on 10/14/2024. As a result, control and accountability of the CS's did not follow state and federal regulations and facility policy and procedures. These deficient practices increased the opportunity for CS diversion (the transfer of a controlled medication or other…
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 before2024-10-18 · 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 practices for 89 of 89 residents when: 1. The dietary staff failed to perform hand hygiene and change gloves when leaving and returning to the tray line to prepare food. 2. The dietary staff failed to wear a N-95 mask (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) appropriately while preparing food on the tray line. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illnesses in all residents who received food from the kitchen. Findings: During an observation of the tray line service for lunch on 10/16/2024 at 11:44 a.m., Dietary Aide (DA) 1's N-95 face mask was not covering her nose and partially covering the mouth. During an observation of the tray line service for lunch on 10/16/2024 at 12:20 p.m. and 12:25 p.m., DA 1 left the tray line…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · 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 interview and record review, the facility failed to notify the responsible party (RP) of a change in condition for one of 19 sampled residents (Resident 79), in the RP's preferred language of Korean (language spoken in the country of Korea). This deficient practice delayed Resident 79's RP's ability to be informed and aware of Resident 79's plan of care, including changes in Resident 79's condition, hospitalizations, and readmissions. Findings: During a review of Resident 79's admission Record, the record indicated Resident 79 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 79's admitting diagnoses included major depressive disorder (a serious mood disorder that affects how a person feels, thinks, and behaves), anxiety disorder (a mental health condition that involves excessive feelings of fear, dread, and uneasiness), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by…
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 before2024-10-18 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop care plans for three of three sampled residents (Resident 72, 37, and 74) addressing the following: a. The hearing difficulties for Resident 72. b. The discomfort of dentures for Resident 37. c. The usage of dentures for Resident 74. These deficient practices placed Resident 72 at risk of an inability to be aware of the care being provided due to staff being unaware of Resident 72's hearing difficulty and need for staff to speak loudly or speak close to hear. These deficient practices also had the potential to delay necessary care, increase the risk of undesired weight loss, and increase the risk of pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) development for Residents 37 and 74. Findings: a. During a review of Resident 72's admission Record, the admission record indicated Resident 72 was admitted to the facility on [DATE]. Resident 72's admitting diagnoses included a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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 observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 31) received appropriate treatment by applying a wrist hand finger orthosis ([WHFO] a device that provides support and help with joint stiffness and contractures [a condition of shortening and hardening of muscles, or other tissue, often leading to deformity and rigidity of joint]), and an elbow splint (a flexible device used to protect and immobilize a body part) as ordered by the physician. This deficient practice placed Resident 31 at increased risk of further decline to the right elbow and wrist contracture. Findings: During a concurrent observation and interview on 10/15/2024 at 10:05 AM, in Resident 31's room, with Resident 31, Resident 31's right arm elbow and wrist was observed without a splint and/or WHFO. Resident 31 stated he was not able to straighten his right arm and hand. Resident 31 stated he should have a splint on his right arm. During a review of Resident 31's admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify fire hazard risks for one of six sampled residents (Resident 23) by not knowing Resident 23 kept a lighter and cigarettes at the bedside. This deficient practice had a potential to increase the risk for injury for Resident 23. Findings: During a concurrent observation and interview on 10/15/2024 at 11:51 AM, in Resident 23's room, a pack of cigarettes and a lighter was observed on top of the nightstand in front of Resident 23's television. Resident 23 stated the lighter and cigarettes belonged to him. During a concurrent observation and interview on 10/16/2024 at 12:34 AM, in the hallway, Resident 23 was observed wheeling himself with a lighter and pack of cigarettes on his lap. Resident 23 stated he had been living in this facility for three and half years, and he kept his lighter and cigarettes with him all the time. Resident 23 stated no staff talked to him regarding the storage of the lighter or cigarettes. During a review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 19 sampled residents (Resident 64) received a meal tray as prescribed by the physician. This deficient practice created the potential for Resident 64 to suffer from repeat weight loss and malnutrition resulting from not receiving his prescribed and expected number of calories and nutritive value. Findings: During a review of Resident 64's admission Record, the record indicated Resident 64 was admitted to the facility on [DATE]. Resident 64's admitting diagnoses included failure to thrive (a syndrome that describes a general decline in health that can include weight loss, poor nutrition, and inactivity), muscle wasting and atrophy (the loss of muscle tissue and strength), dehydration, and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). During a review of Resident 64's History and Physical (H&P), dated 4/11/2024, the H&P indicated Resident 64 did not have the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · 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 store and discard (remove, destroy) one expired insulin (short-acting regular human insulin) Novolin R (type of insulin injection device) vial for Resident 53 from use, in accordance with facility and manufacturer requirements, in one of one inspected medication room (Medication Room Nursing Station 2.) This deficient practice increased the risk that Resident 53 could have received medication that had become ineffective or toxic due to improper storage, possibly leading to health complications. Findings: During an observation on [DATE] at 12:23 pm, in Medication Room Nursing Station 2, in the presence of Registered Nurse (RN) 2, one opened insulin Novolin R vial for Resident 53 was found stored in the refrigerator with a label indicating use began on [DATE]. According to the manufacturer's product labeling, opened Novolin R vials should be stored at room temperature up to 77 degrees Fahrenheit and used or discarded within 42 days 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 · Dcited before2024-10-18 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor the food choices and offer alternative menu options for one of six sampled residents (Resident 15). This deficient practice had the potential to impact Resident 15's nutritional status, quality of life and result in food dissatisfaction leading to insufficient food intake. Findings: During a review of Resident 15's admission Record, dated 8/23/2024, the admission record indicated Resident 15 was admitted to the facility on [DATE]. Resident 15's diagnoses included congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 15's Minimum Data Set (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.
- Potential for harm · D2024-03-08 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to manage pain for one of three sampled residents (Resident 1) by failing to ensure Resident 1's pain medication was available and administered for severe pain as ordered by the physician and according to the resident's care plan. This deficient practice resulted a delay in treatment and unrelieved pain for Resident 1. Findings: During a review of Resident 1's admission Record (Face sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes (high blood sugar), hypertension (high blood pressure), and low back pain. During a review of Resident 1's care plan titled, At risk for pain/general discomfort related to back pain and spinal problem dated 11/6/2023, the care plan interventions indicated to administer medication for mild, moderate and severe pain as ordered or as needed. During a review of Resident 1's History and Physical (H&P) dated 11/9/2023, the H&P indicated Resident 1 had the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-08 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
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 maintain the toilet in safe condition for 1 of 3 residents' toilets, (Resident 1). This deficient practice placed the resident at risk for falls and injuries. Findings During a review of Resident 1's admission, the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes (high blood sugar), hypertension (high blood pressure), and low back pain. During a review of Resident 1's history and physical (H&P) dated 11/9/2023, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1's minimum data set ([MDS] a standardized care assessment and care screening tool), dated 11/12/2023, the MDS indicated Resident 1's cognitive skills (thought process) was intact and was ablet to understand and be understood by others. The MDS indicated Resident 1 required extensive assistance with one to two persons assist with activities such as…
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 · E2023-10-20 · tag F0578 — failed to honor advance directives / code status — patternHonor 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: 1. Ensure the Advance Directives (a written statement of a person's wishes regarding medical treatment) of two of 12 sampled residents' (Residents 86 and 88), were completed by the residents and/or their responsible parties. This deficient practice violated the residents' and/or the responsible parties' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. 2. Implement its policy and procedure titled, Policy for Conservator/Public Guardian Signing Physician Orders for Life Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) for 1 of 6 residents, Resident 37, whose POLST form was left blank. This failure had the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-20 · 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: 1. Expired mustard packets in the dry storage room was discarded after its expiration date. 2. Dietary aide performed hand hygiene after removing gloves during the tray line (preparation of food), touching menu book and returning to tray line to continue preparing meal trays. These deficient practices had the potential to cause food-borne illnesses. Findings: a. During an observation of the kitchen, on 10/17/2023 at 8:59 a.m., while in the dry storage area, mustard packets were observed in a bin sitting on pantry shelf. The Mustard packets were labeled with a received date of 10/14/2022 and an expiration date of 10/14/2023. During a concurrent observation and interview, on 10/17/2023 at 9:13 a.m., the Dietary Supervisor (DS) stated the facility's protocol should have been to discard the mustard on or after 10/14/2023. DS proceeded to discard the expired mustard packets. DS stated the risk of providing residents with expired mustard packets is, It can be bad for the residents and get them sick. I will…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-20 · 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 ensure the two dryers were free of lints, and to maintain a log to record maintenance for lint removal and water temperature. These failures places the facility at high risk for fire when the dryer was not maintained in a safe manner and the potential to increase the risk of spreading bacteria when resident clothes and linens are not washed with the right water temperature. Findings: During a concurrent interview and record review on 10/17/2023 at 1:15 p.m., with the maintenance supervisor, the water temperature and lint removal logs for October 2023 were reviewed. The water temperature and lint removal logs for 10/16/2023 a.m. shift were not documented. The maintenance supervisor stated the failure of not documenting the water temperature log may cause improper laundering of resident's clothes and linens because of the water temperature that needed to be used and maintained. The failure of not documenting the lint removal log may increase the risk of fire because the lint had to be removed and the lint…
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
$13,635 in federal fines across 1 penalty.
- $13,635 — penalty dated 2023-09-25
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 IL & JOAN LEE — 4 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 | 2 of 5 | 2.0 | ≈ chain avg |
| Health inspection | 4 of 5 | 2.5 | +1.5 vs chain |
| Staffing | 1 of 5 | 2.8 | -1.8 vs chain |
| Quality measures | 1 of 5 | 2.8 | -1.8 vs chain |
The other 3 homes this chain runs (chain average 2.0★, 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 | Since |
|---|---|---|---|
| LEE, JOAN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; LIMITED PARTNERSHIP INTEREST | since 05/01/2007 |
| LEE, IL | Individual | LIMITED PARTNERSHIP INTEREST | since 05/01/2007 |
CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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 $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555865. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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