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Lotus Care Center

6011 West Blvd, Los Angeles, CA 90043 · For profit - Corporation · 40 certified beds · (323) 292-0749 Medicare & Medicaid certified

Call the home — (323) 292-0749 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 24 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 25% of its spending goes to commonly-owned related companies

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

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

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

Location & what’s nearby

Hospital
Urgent care / clinic
5456 Valley Ridge Ave · (323) 296-8671 · Call to confirm hours
Pharmacy
Grocery
3753 W Slauson Ave · (323) 292-0305 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 held steady at 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased23.3%10.2%15.4%worse
Long-stay residents who lose too much weight8.1%4.0%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened8.0%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.9%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers0.0%4.3%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control1.8%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 table52.4%12.0%17.1%check this — see note marked dagger below the table
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission28.2%23.0%22.6%worse
Short-stay residents with an outpatient ER visit4.3%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days3.752.251.67worse
Long-stay outpatient ER visits per 1,000 resident days0.261.571.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.

25.1% 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 86 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

25.1%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
85.1%U.S. median 56.6%
Met the expected recovery
0.53U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.16hours / resident / day
Speech therapy

Met the expected recovery: 85.1% 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 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 0.53 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 36% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF25.1%CMS range 17.8–37.651.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 8.0–14.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge85.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge77.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge82.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified94.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge78.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 3.8–12.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.481.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.39
RN hours/ resident / day
0.78
LPN hours/ resident / day
2.98
Aide hours/ resident / day
4.16
Total nurse hours/ resident / day
0.36
RN hoursweekends
35.7%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 40 beds and averages 35.4 residents a day — about 88% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.16 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.98 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.17 hrs/resident/day on weekends vs 4.15 on weekdays — about the same on weekends as weekdays. RN hours go from 0.41 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% 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

6
deficiencies at the latest standard inspection (2026-02-13)
10
at the previous standard inspection (2024-10-18)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · Ecited before2026-02-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to: Ensure the lid on an opened container of jelly was closed.Ensure a package of sandwich meat was stored in a closed container after being opened.Ensure staff were monitoring temperatures in 2/2 dry food storage rooms by placing thermometers inside. These deficient practices had the potential to result in contamination of food served to the residents.Findings: During an observation on 2/11/2026 at 8:20 am of the kitchen refrigerator, there was a square plastic container labeled jelly with a lid not closed on all four sides, and there was an opened plastic bag of sliced meat uncovered. During a concurrent observation and interview on 2/11/2026 at 8:20 am in the kitchen with the [NAME] (CK), the CK stated the lid of the jelly should have been closed on all four sides and the sandwich meat should have been put into a closed container. The CK stated the food could grow bacteria or become contaminated from not being in a closed container. During an observation on 2/11/2026 at 11:30 am in the kitchen's dry storage…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-13 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 one of five sampled residents (Resident 30) Practitioner Orders for Life-Sustaining Treatment ([POLST] - a medical order form that documents specific medical treatment in the event of a medical emergency) part D of the form was completed.This deficient practice of not having the POLST completed had the potential for Resident 30's wishes not to be carried out in the time of distress. During a review of Resident 30's admission Record (Face Sheet), the Face Sheet indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 30's diagnoses included pleural effusion (accumulation of excess fluid in the pleural spaces between the lungs), heart failure (heart muscle cannot pump enough blood to meet the body's metabolic needs), and chronic obstructive pulmonary ([COPD]- a chronic lung disease causing difficulty in breathing).During a review of Resident 30's History and Physical (H&P), dated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-13 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Report to the physician a change in condition when sediments (the solid matter that settles to the bottom of a liquid, such as urine) and cloudy urine were observed in the indwelling urine catheter (a medical device inserted into the bladder to drain urine continuously) tubing for one of one sampled resident (Resident 2). This deficient practice had the potential to delay clinical assessment and timely medical intervention. Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/17/2023 and readmitted on [DATE] with diagnoses including malignant neoplasm of prostate (prostate cancer), chronic kidney disease (CKD - condition which the kidneys are damaged and cannot filter blood as well as they should), benign prostatic hyperplasia (BPH - enlargement of the prostate gland that compresses the urethra[a tube that lets urine leave your body], causing symptoms 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-13 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure the Minimum Data Set (MDS) resident assessment accurately reflected tobacco use status for two of 13 sampled residents (Residents 8 and 17). The MDS coded the residents as non-tobacco users despite documentation and staff confirming tobacco use within the required look-back period. This deficient practice had the potential to affect the accuracy of resident assessment data used for care planning, quality measures, and facility monitoring of smoking-related safety needs. Findings:A.During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 on 6/4/2025 and readmitted on [DATE] with diagnoses including epilepsy (recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body), schizoaffective disorder-bipolar type (a mental illness that can affect thoughts, mood, and behavior) unspecified dementia (general term for the impaired ability to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-13 · tag F0908 — failed to keep essential equipment working — isolated
    Keep 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: 1. Maintain equipment in the kitchen when it was observed that the freezer was not kept at a temperature less than or equal to 0 degrees Fahrenheit. This deficient practice had the potential to result in contamination of food served to the residents.Findings: During an observation on 2/11/2026 at 8:40 am in the kitchen, 1/2 freezer's thermometer indicated a temperature of 48 degrees Fahrenheit (F). During a concurrent observation, interview, and record review on 2/11/2026 at 8:30 am in the kitchen with the [NAME] (CK), the thermometer inside the freezer indicated a temperature of 48 degrees F. The CK stated the freezer temperature should be 0 degrees F or less to keep bacteria from growing on the food. A review of the temperature log taped to the freezer titled Reach-In Refrigerator, dated February 2026 was reviewed. The temperature on days labeled 7 through 11 indicated temperatures of -4, 20, 28, 50, and 50 degrees F. The CK confirmed the log was for the freezer and stated that it had been broken for a few…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-10-18 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food items were stored in a manner to prevent the growth of microorganisms that could cause food borne illnesses (any illness resulting from spoiled or contaminated food). This deficient practice had the potential to cause food borne illnesses for residents in the facility. Findings: During an observation on 10/15/2024 at 8:40 AM, in the kitchen dry storage room, the following findings were observed: 1. One container of peanut butter was found to have sticky residue and jelly like substance on the outside of the container. 2. One bottle of liquid smoke was found to have sticky residue on the outside of the container. During an interview on 10/15/2024 at 8:48 AM with the Dietary Supervisor (DS), the DS was shown the container of peanut butter and bottle of liquid smoke. The DS stated the container had sticky residue on both the containers and it was important to ensure food containers were clean to prevent attracting pests and roaches to food storage areas. During a review of the facility's policy and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-10-18 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the laundry room was free from personal food items. This deficient practice had the potential to spread infection throughout the facility. Findings: During an observation on 10/17/2024 at 7:49 AM, in the laundry room, a bag of dried food items was observed on a chair next to a table where clean linens were folded and where clean residents clothing were stored below. There was also a small orange and a jar of sugar packets in the drawer where personal protection equipment (PPE) was stored. During an interview on 10/17/2024 at 8:01 AM with the Laundry Aide (LA) and Certified Nurse Assistant (CNA) 1, the LA stated staff stored their food in the laundry room, but did not eat it in the laundry room. The LA stated staff ate in the break room. CNA 1 stated having food around clean linen and PPE was an infection control risk which could also cause bad odors in the laundry room. During an interview on 10/18/2024 at 10:33 AM with the Director of Nursing (DON), the DON stated if food items were kept in the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-18 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS]- a federally mandated assessment tool), for one of eight sampled residents (Resident 1). This deficient practice had the potential to result in inaccurate care and services for Resident 1 due to inappropriate MDS care screening and assessment tool practices. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior), anxiety (a feeling of uneasiness or fear), and depression. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated Resident 1 was receiving Risperidone (a medication for schizophrenia) 3 milligrams ([mg]- a unit of measurement) twice a day. During a review of Resident 1's care plan, dated 9/13/2024, the care plan indicated Resident had…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 15) had a care plan developed to address smoking. This deficient practice had the potential to result in a lack of monitoring and risk of injury. Findings: During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was admitted to the facility on [DATE]. Resident 15's diagnoses included heart failure (weakened heart), bipolar disorder (mental illness that causes extreme shifts in mood), and schizophrenia (mental disorder that affects a person's thoughts/perceptions). During a review of Resident 15's History and Physical (H&P), dated 8/15/2024, the H&P indicated Resident 15 could make her needs known but did not have capacity to consent. During a review of Resident 15's Minimum Data Set ([MDS] a standardized federally mandated assessment tool) dated 9/6/2024, the MDS indicated Resident 15's cognition (gaining knowledge and understanding) was intact. During a concurrent…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 complete a change of condition and notify the doctor of bruising for one out of one sampled resident (Resident 24) who was receiving Eliquis (a blood thinning medication). This deficient practice had the potential to delay necessary care and services for Resident 24. Findings: During a concurrent observation and interview on 10/15/2024 at 3:29 PM, with Resident 24 outside of his room, observed both of Resident 24's hands. Resident 24's hands were observed with a dark purplish discoloration by the thumb with the left side being worse than the right. Resident 24 stated he did not know where the bruising came from, and denied falling, being hit, or accidentally hitting his hands against something. Resident 24 stated the nurses were aware of the bruising but did not recall which nurse knew about it. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE]. Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2024-10-18 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure one out of five sampled employees had an annual skills checklist completed. This deficient practice had the potential to result in substandard quality of care to residents due to a lack of training/assessment. Findings: During a concurrent interview and record review on 10/16/2024 at 3:57 p.m. with the Director of Staff Development (DSD), the employee file for Certified Nursing Assistant (CNA) 2 was reviewed. The DSD stated CNA 2 was hired on 12/21/2022. The DSD could not provide a completed annual skills checklist. The DSD stated CNA 2 should have had an annual skills checklist completed in December 2023. The DSD stated the checklist was important to ensure CNA 2 was competent and understood her job. The DSD stated the check list helped make sure things were done accurately. The DSD stated if the skills check list was not completed, care for the resident may not be done properly. During an interview on 10/17/2024 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the skills check list should be…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 27) received a monthly Medication Regimen Review ([MRR] evaluation of medications to identify issues) by the pharmacist. This deficient practice put Resident 27 at risk for an adverse drug reaction (harmful response). Findings: During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's diagnoses included heart failure (weakened heart), bipolar disorder (mental illness that causes extreme shifts in mood), and schizophrenia (mental disorder that affects a person's thoughts/perceptions). During a review of Resident 27's History and Physical (H&P), dated 6/3/24, the H&P indicated Resident 27 could make needs known but could not make medical decisions. During a review of Resident 27's Minimum Data Set ([MDS] a federally mandated assessment tool) dated 9/7/24, the MDS indicated Resident 27 had moderate cognitive impairment…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-18 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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

    Based on observation, interview, and record review, the facility failed to ensure three bottles of Enulose (medication used to help with a brain disorder caused by liver disease) in medication Cart 1 was free of sticky residue. This deficient practice put residents at risk for infection related to cross contamination (transfer of bacteria from one object another). Findings: During an observation on 10/15/24 at 12:30 p.m at Medication Cart 1, three bottles of Enulose were found with sticky residue on the outside of the container. During a concurrent observation and interview on 10/15/24 at 12:35 p.m. with Licensed Vocational Nurse (LVN) 1 at Medication Cart 1, LVN 1 picked up the Enulose bottle and stated, It's sticky. LVN 1 stated there was a risk of cross contamination from the hands to bottle. LVN 1 stated a resident could be injured if they were allergic to the medication, and it was transferred to them from the nurse's hands. LVN 1 stated per policy, the bottle should be wiped off. During an interview on 10/17/24 at 2:34 p.m. with the Director of Nursing (DON), the DON stated…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure all dumpsters were kept closed. This deficient practice had the potential to attract flies and rodents to the dumpster area. Findings: During an observation on 10/15/2024 at 9:15 a.m. one out of two dumpsters were noted to have the lid off. During an interview on 10/17/2024 at 8:02 a.m. with the Maintenance Supervisor (MS), the MS stated the dumpster should be closed at all times. The MS stated if the dumpster was left open it could attract flies and rats. The MS stated rats could get into the facility. During an interview on 10/17/2024 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the dumpster should be closed at all times to prevent harboring of insects and odor. The DON stated an open dumpster could attract rodents and insects. During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, dated October 2017, the P&P indicated all garbage containers must be kept covered.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of eight sampled residents (Resident 24). This deficient practice had the potential to negatively impact the continuity of care and delivery of services for Resident 24. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE]. Resident 24's diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (a mental illness that causes extreme shifts in mood, energy, and activity levels), and depression. During a review of Resident 24's Minimum Data Set ([MDS]- a federally mandated assessment tool), dated 9/13/2024, the MDS indicated Resident 24 had moderately impaired cognition (ability to reason, understand, remember, judge, and learn). During a review of Resident 24's Licensed Nurses Progress Notes, dated 9/10/2024 at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-25 · tag F0908 — failed to keep essential equipment working — pattern
    Keep 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 interview and record review, the facility failed to ensure the facility ' s telephone system was able to receive outside calls from one of three resident ' s (Resident 1) representative or an outside caller. This deficient practice had the potential for all the residents in the facility not receiving phone calls from family members. Findings: 1). 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 Stage four (4) pressure ulcer (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones) on the sacral (tail bone) region and muscle weakness. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardize care screening and assessment tool) dated 9/23/2024, the MDS indicated Resident could understand and be understood by others. The MDS indicated Resident 1 was dependent and required a two or more person ' s assist with activities of daily living…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the low air loss mattress ([LAL] special mattress for wound management) for one of three sampled residents (Resident 1), as ordered by the physician. This failure placed the resident ' s wound at risk for poor healing and worsening condition. 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 Stage four (4) pressure ulcer (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones)on the sacral (tail bone) region and muscle weakness. During a review of Resident 1 ' s Order Summary Report dated 9/19/2024, the Order Summary Report indicated a LAL mattress every shift. During a review of Resident 1 ' s care plan titled, Alteration in skin condition, dated 9/19/2024, the interventions indicated to provide pressure relieving surface as ordered. During a review of Resident 1…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-22 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure, two of seven sampled residents (Resident 3 and Resident 32), were assisted with nail hygiene and Resident 32 did not have a dry and scaly feet. This deficient practice had the potential for Resident 3 and Resident 32 to scratch themselves, result in itchy skin and can result in skin breakdown. Findings: a. During a review of Resident 3's admission record, the admission record indicated Resident 3 was admitted on [DATE], with a diagnosis that included cognitive communication deficit (an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness.), diabetes (abnormal blood sugar), and hypertension (high blood pressure) During a review of Resident 3's history and physical (H&P) dated 5/3/2023, the H&P indicated Resident 3 had the mental capacity to make needs known but cannot make medical decisions. During a review of Resident 3'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-22 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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 observations, interviews, and record reviews, the facility failed to to ensure hygiene products that were stored in the facility's central supply room were not expired. This deficient practice had the potential for the products to lose its effectiveness and strength and can result to a skin reaction or any adverse reactions to the residents. Findings: During an observation on [DATE] at 8:10 a.m. of the central supply room, 20 bottles of baby powder had an expiration date of [DATE], 48 morning fresh (brand) toothpaste tubes had an expiration date of 9/2023, two (2) boxes of denture cleaner had an expiration date of 9/2023 and 30 bottles of mouth wash had an expiration date of [DATE]. During an interview on [DATE] at 5:32 p.m., with Registered Nurse (RN) 1, RN 1 stated, the central supply room contained all hygiene products the resident needed for their activities of daily care (ADLS, maintaining a safe environment, communication, breathing, eating, and drinking, elimination, washing and dressing] such…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-22 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for two out of 17 sampled residents (Resident 28 and 22) Level 2 (a person-centered evaluation completed for anyone identified by the Level I Screening as having, or suspected of having, a PASRR condition, i.e serious mental illness, intellectual disability, developmental disability or related condition to determine whether placement or continued stay in a Nursing Facility is appropriate), were completed. Resident 28, who had a PASRR positive Level 1 (a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified Nursing Facility in order to determine whether an individual might have a mental illness or intellectual disability), was not screened for Level 2 by a Level 2 contractor (by evaluators from The Department of Health Care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-22 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food products stored in the freezer were labeled use by dates (last date recommended for the use of the product while at peak quality) as per the facility's policy and procedure. This deficient practice can affect the palatability (taste) of the food prepared and had the potential to place the residents at risk for food borne illnesses. Findings During an observation on 10/21/2023 at 7:44 a.m. in the kitchen, three bags of hash browns and three bags of tater tots (shaped diced potatoes for cooking) were in the freezer and had no label when the bags were received and had no use by (last date recommended for the use of the product while at peak quality) dates. During an interview with the kitchen manager (KM) on 10/21/2023 at 7:50 a.m., the KM stated the bags of hash browns and tater tots were not expired but the bags did not have a blue label indicating when the bags were received and when to use the bags by. During another interview with the KM on 10/22/2023 at 1:26 p.m., the KM stated when food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2026-02-13 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure each resident had at least 80 square feet ([sq. ft.]- is a unit of, area measurement) of measured living space in rooms 1, 6, 7, 8, 9, 11,12,15,16, and 17.This deficient practice had the potential to result in residents not being able to move around freely, store personal items, and for staff to have difficulty providing care for the residents due to the lack of space. During an observation on 2/13/2026 at 2:15 p.m., room [ROOM NUMBER] had three occupied residents' beds with a total of four beds in the room.During a review of the Client Accommodations Analysis (form that indicates room measurements and capacity), dated 2/13/2026, the client accommodations analysis indicated the facility had the following room measurements:Room Number Sq Ft Number of Beds 1 125 2 6 138 2 7 156 2 8 156 2 9 141 2 11 295 4 12 295 4 14 295 4 15 295 4 16 295 4 17 295 4 During an interview on 2/13/2026 at 3:14 p.m., with Director of Nursing (DON), 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2024-10-18 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident had at least 80 square feet (sqft, unit of measure of living space in Rooms 1, 6, 7, 8, 9, 11, 12, 14, 15, 16, and 17. This deficient practice had the potential to result in residents not being able to move around freely or store personal items, and staff may also have difficulty providing care due to a lack of space. Findings: During an observation on 10/17/2024 at 10:18 a.m., in room [ROOM NUMBER], room [ROOM NUMBER] was observed with four occupied beds. During an interview on 10/17/2024 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the residents may have limited space to move around. The DON stated there was a potential less space could affect patient care. During a review of the Client Accommodations Analysis (form that indicates room measurement and capacity), dated 10/17/2024, the client accommodations analysis indicated the facility had the following room measurements: Room Number: Number of…

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

    Environmental Deficiencies · Waiver has been granted
  • No harm found · Bcited before2023-10-22 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to meet the required 80 square feet per resident in a multiple resident bedrooms (Rooms 1, 6, 7, 8, 9, 11, 12, 14, 15, 16 and 17) and 100 square feet per resident in single resident rooms (Rooms 2, 3, 4, 5, 10). This deficient practice had the reduced required space for each resident which had the potential for inadequate space during resident care, and or the inability for resident access, use of personal assistive devices, furniture, and enough space for the visitors. Findings: During a concurrent observation of the resident rooms and interview with the Maintenance Supervisor (MS) on 10/22/2023 at 7:44 a.m., the MS stated several of the bedrooms were smaller than required. During a review of the facility's Client Accommodations Analysis form, the form indicated the following resident bedrooms measurements: Room Numbers Number of Beds Total Square feet 1 2 125.28 2, 3, 4, 5 1 97.51 6 2 138.88 7 2 156.75 8 2 156.75 9 2 141.36 10 2 160.31 11 4 290.67 12, 14, 15 ,16, 17 4 295.32 During a review of the waiver…

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

    Environmental Deficiencies · Waiver has been granted

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
SB 2020 PROTECTIVE TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 03/01/2023
TB 2020 PROTECTIVE TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 03/01/2023
BHATIA, SONAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER50%since 03/01/2023
BHATIA, TANIAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER50%since 03/01/2023
GREAT NECK MANAGEMENT INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2015

CMS files one row per role, so the 10 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$6.4M
Net patient revenuemost recent cost report
-0.5%
Operating marginrevenue minus expenses
$1.6M
Related-party expense25% of expenses
Who pays — share of resident-days
Medicaid 56%Medicare 41%Other / private 3%

This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 25% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$494per resident / day
operating cost
$15,024per month
≈ monthly operating cost
$492per day
avg. revenue, all payers

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

What families pay in CA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555040. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

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.

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