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Pih Health Good Samaritan Hospital D/P SNF

1225 Wilshire Blvd, Los Angeles, CA 90017 · Non profit - Corporation · 28 certified beds · (213) 202-7050 Medicare & Medicaid certified

Call the home — (213) 202-7050 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Dec 2025Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (5/5) — 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 (5/5)
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (2/5)
  • about 100% 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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 5 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Urgent care / clinic
1313 West 8th Street, Suite 100
Pharmacy
1234 Wilshire Blvd · (213) 481-1130 · Call to confirm hours
Grocery
Food Land0.1 mi
739 S Union Ave · (213) 483-2390 · Call to confirm hours
Park
8TH St · 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 2 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Short-stay residents who newly got an antipsychotic medication0.8%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine90.0%93.2%79.4%better
Short-stay residents rehospitalized after admission32.6%23.0%22.6%worse
Short-stay residents with an outpatient ER visit7.6%11.2%12.0%better

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.

45.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 72 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.4%U.S. median 51.5%
Got home and stayed home
9.3%U.S. median 10.7%
Went back to hospital
8.6%U.S. median 56.6%
Met the expected recovery
1.19U.S. median 0.31
Therapy hours / resident / day
0.69hours / resident / day
Physical therapy
0.49hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 8.6% 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 58 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 1.19 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 49% 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 SNF45.4%CMS range 35.6–52.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.3%CMS range 6.7–13.310.7%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 discharge8.6%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 discharge8.6%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 discharge6.9%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 identified86.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting97.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 3.8–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.951.02Oct 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

5.00
RN hours/ resident / day
2.05
LPN hours/ resident / day
3.55
Aide hours/ resident / day
10.60
Total nurse hours/ resident / day
3.83
RN hoursweekends
29.3%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 28 beds and averages 23.7 residents a day — about 85% occupied, or roughly 4 beds typically open. It usually has some room. 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 10.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 5.00 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.55 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 9.46 hrs/resident/day on weekends vs 11.05 on weekdays — 14% thinner on weekends. RN hours go from 5.46 to 3.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

2
deficiencies at the latest standard inspection (2025-12-04)
8
at the previous standard inspection (2024-10-04)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · D2025-12-04 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to document the removal or release of mittens and wrist restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one out of one sampled resident (Resident 46). There was no evidence in Resident 46's record indicating that the restraints were removed or released for monitoring or assessment during the shift. Failure to document the removal or release of restraints (such as mittens or wrist restraints) violates the requirement for ongoing monitoring and documentation, which is essential to ensure the restraint is medically necessary and not used for convenience or discipline. This failure had the potential to compromise Resident 46's rights and safety. This had a potential for risk for harm such as skin breakdown, restricted circulation, or psychosocial distress due to prolonged restraint.Findings: During a review of Resident 46's…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-04 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 professional standards of dialysis care for one of three sampled residents (Resident 34) by failing to ensure the provision of appropriate emergency equipment like hemodialysis emergency kit (Emergency bleeding control kit to control bleeding in the event of a dialysis-related complication ) is available at bedside for Resident 34 who had dialysis fistula (a surgically created connection between an artery and a vein, usually in the arm, to provide reliable, long-lasting access for dialysis). The kit typically includes critical items such as a tourniquet, pressure bandages, gauze, and a clamp or hemostat (a specialized clamp like pliers or scissors used to compress/pinch blood vessels), which are essential for immediate bleeding control. This failure had the potential to result in delayed response to a bleeding episode, placing Resident 34 at risk for significant blood loss, compromised safety, and adverse health outcomes.Findings: During a review of Resident 34's admission Record, the admission Record…

    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 · D2025-07-01 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    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 Resident 1 was included in the discharge planning process.This failure had the potential to result in Resident 1's preferences not being incorporated in his own discharge plan. During a review of Resident 1's History and Physical (H&P), dated 5/30/2025, the H&P indicated, Resident 1 admitted to the facility on [DATE] for a hypertensive (elevated blood pressure) emergency with a past medical history of end stage renal disease (ESRD - kidney failure) on hemodialysis (a medical procedure that cleans the blood of a person whose kidneys are not functioning properly), peripheral artery disease (PAD - a condition where blood vessels outside of the heart, particularly those supplying the limbs, become narrowed or blocked, reducing blood flow to the extremities), left below the knee amputation (the surgical removal of a body part) and right foot first and third digit amputation.During a concurrent interview and record review on 7/1/2025 at 11:47 AM with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-10-04 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to submit their Payroll Based Journal (PBJ, information of the provider's daily staffing hours for the appropriate care of the residents) report to Center for Medicare Services (CMS) in a complete and accurate manner. This deficient practice prevented the provision of complete and accurate direct care staffing information to the public. Findings: A review of the CMS PBJ Staffing Report indicated during the first fiscal quarter of 2024 dated 10/1/2023 to 12/31/2023, there was excessively low weekend staffing data triggered. During the second fiscal quarter of 2024 dated 1/1/24 to 3/31/2024, the PBJ report indicated no Registered Nurse (RN) hours were triggered (four or more days within the quarter with no RN hours). The third fiscal quarter of 2024 dated 4/1/2024 to 6/30/2024, indicated one Star Staffing Rating and excessively low weekend staffing were triggered. A review of the CMS Submission Report for the first fiscal quarter dated 2/13/2024, indicated the facility submitted 86 employee records and 1840 total staffing hour…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-04 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure comprehensive, resident -centered care plans were developed for four of ten sampled residents (Residents 111, 115, 163 and 166). For Resident 111 the facility failed to develop a care plan to address the resident's non-compliance to take medications. -For Resident 115 the facility failed to develop a care plan with person centered interventions for psychotropic medication (medications that affect brain activities associated with mental processes and behavior) use. -For Resident 163 the facility failed to develop a care plan including measurable goals and interventions to monitor oxygen use. -For Resident 166 the facility failed to develop a care plan including measurable goals and interventions for the resident's multiple wounds. These deficient practices had the potential for the residents to receive inadequate care and services. Findings: a. A review of Resident 111's Facesheet Report, indicated the facility admitted the resident on 9/25/2024 with a diagnoses including right foot gangrene (a serious condition that…

    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 · D2024-10-04 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' Minimum Data Set assessments (MDS, a federally mandated resident assessment tool) were transmitted timely to the Center for Medicare Services (CMS) system for two of 10 sampled residents (Resident 3 and Resident 4). This deficient practice had the potential to result in delayed services for Resident 3 and Resident 4. Findings: A review of Resident 3's Facesheet Report indicated the facility admitted the resident on 3/27/2024 with a diagnoses including right femur fracture (broken thighbone) and was discharged from the facility on 4/10/2024. A review of Resident 3's MDS dated [DATE], indicated the resident was cognitively intact (has the ability to think, remember, express thoughts and make decisions). The MDS indicated Resident 3 was independent with eating and required set up or clean up assistance with oral hygiene. The MDS indicated Resident 3 required supervision or touching assistance for upper body dressing and personal hygiene.…

    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 · D2024-10-04 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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 timely and accurately complete a discharge summary for two of four sampled residents (Resident 8 and Resident 9). For Resident 8, there was no discharge summary completed within 14 days of the resident being discharged . For Resident 9, the discharge summary did not include a final summary of the resident's status. These deficient practices caused an increased risk in the continuing care of the residents. Findings: a. A review of Resident 8's Facesheet Report indicated the facility admitted the resident on 7/1/2024 with diagnoses including chest pain. A review of the Physician's Order dated 7/5/2024, indicated Resident 8 was discharged to the acute hospital and was to be transferred to the telemetry unit (a hospital ward where patients are continuously monitored for their cardiac activity and other vital signs) for anemia and hyperkalemia treatment. A review of the Discharge summary dated [DATE], indicated Resident 8's discharge diagnoses were…

    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 · D2024-10-04 · 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 ensure one of ten sampled residents (Residents 166 ) received care and treatment to promote healing of wounds, as ordered by the physician. This deficient practice caused an increased risk of worsening of the wounds and potential infection for Resident 166. Findings: A review of Resident 166's facesheet report indicated the resident was admitted to the facility on [DATE] with diagnoses including failure to thrive (a condition characterized by the gradual decline in physical or mental function, resulting in an overall decline in well-being). A review of Resident 163's Active Orders, dated 9/30/2024 indicated the following wound care orders: -Paint the wound on Left Lower Extremity (LLE), left first and second toe with Betadine swab, keep it open to air every day. -Paint the wound on right first toe, left medial (middle area) ankle, left plantar (sole), lateral(side) foot and left heel with Betadine swab, keep it open to air daily. - Paint…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-04 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 sampled resident(Resident 115), who was receiving nutrition by gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), received appropriate care and services to prevent complications of enteral feeding (tube feeding, a way of delivering nutrition directly to your stomach or small intestine). This deficient practice had the potential to lead to the inadequate care of Resident 115 and place the resident at an increased risk for complications such as infection. Findings: A review of Resident 115's admission Record (Face Sheet) indicated the facility admitted the resident on 9/19/2024, with diagnoses including gastrostomy tube, schizophrenia (a serious mental condition involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, bipolar disease (a mental health condition that causes extreme mood swings), and history of aphasia (a disorder that results from damage to portions 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-04 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 two of five sampled residents (Residents 113 and 115) were free from unnecessary use of psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure. For Resident 115, there was no measurable target behaviors related to the use of three antipsychotic medications. For Resident 113, there was no measurable target behaviors related to the use of two antidepressant medications. These deficient practices had the potential to place Resident 113 and Resident 115 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status. Findings: a. A review of Resident 115's admission Record (Face Sheet) indicated the facility admitted the resident on 9/19/2024, with diagnoses including gastrostomy tube (GT- a tube surgically inserted…

    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
Show the remaining 12 citations
  • Potential for harm · D2024-10-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to implement infection control measures for one of 10 sampled residents (Resident 63). For Resident 63, the intravenous catheter (IV, a soft, flexible tube placed inside a vein, usually in the hand or arm. A medical technique that administers medication, fluids, and/or nutrients directly into a person's vein) was not discontinued / removed when clinically indicated. This deficient practice caused an increased risk to infection control issues and the potential of the resident experiencing phlebitis (inflammation of the vein). Findings: A review of Resident 63's Facesheet Report indicated the facility admitted the resident on 9/18/2024 with a diagnoses including failure to thrive (state of decline that may include weight loss, decreased appetite, poor nutrition, inactivity, and moderate protein-calorie malnutrition [lack of proper nutrition)]. A review of Resident 63's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/30/2024, indicated the resident was cognitively intact (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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-10-06 · tag F0636 — widespread
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 complete and/or submit the Minimum Data Sets (MDS - a comprehensive standardized assessment and screening tool) within the required time frame for six of 19 sampled residents (Residents 8, 10, 13, 57, 110 and 111). This deficient practice had the potential to negatively affect the provision of necessary care and services for Residents 8, 10, 13, 57, 110 and 111. Findings: a. A review of Resident 8's admission record indicated the facility admitted the resident on 9/2/2023. A review of Resident 8's admission nursing assessment, dated 9/2/2023, indicated the resident was alert and oriented to person place and time, also that Resident 8 denied pain and was using oxygen. The admission nursing assessment did not indicate the nurse assessed the resident's ability to perform activities of daily living (essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet), the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-06 · tag F0732 — pattern
    Post nurse staffing information every day.
    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 post daily actual hours or projected hours worked by the licensed and unlicensed staff providing direct care to the residents per shift and failed to complete the Direct Care Service Hours Per Patient Day (DHPPD - refers to the actual hours of work performed per patient day by a direct caregiver) for 9/3/2023 to 10/4/2023. As a result, staffing information of the unit was not complete and accurate for residents and visitors. Findings: During an interview on 10/5/2023 at 10:53 AM, Clinical Director (CD) stated she was also the unit's Director of Staff Development. During a concurrent observation with the CD, the staffing was posted on the unit and indicated on 10/2/2023 there were three registered nurses and two certified nursing assistants on the day shift (7 AM to 7 PM). the posted staffing also indicated there were two registered nurses, two licensed vocational nurses and two certified nursing assistants on the night shift (7 PM to 7 AM). During a concurrent interview and record review on 10/5/2023 at 3:58…

    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 · D2023-10-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to reasonably accommodate Resident 8's physical limitations by providing a soft bell call light within easy reach. This failure had the potential for Resident 8 to be unable to maintain or achieve independent functioning, dignity, and well-being. Findings: A review of Resident 8's face sheet report indicated the resident was admitted to the facility on [DATE] for weakness with diagnsoes including toxic encephalopathy (exposure to toxic substances that changes the brain function or structure), acute respiratory failure (happens suddenly that is caused by a disease or injury to the lungs affecting breathing), cellulitis (a common but serious skin infection) of the right lower limb (leg), and rhabdomyolysis (muscle tissue breakdown damaging the kidneys). A review of Resident 8's Care Plan dated 9/28/2023 indicated a call light was in place. The CP did not indicate Resident 8 refused to use the call light and preferred to scream for assistance.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-06 · 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

    Based on interview and record review, the facility failed to assist one of six sampled residents (Resident 57) in formulating an Advance Directive (a legal document that tells your doctor your wishes about your health care if you cannot make the decisions yourself). This deficient practice had the potential to inhibit Resident 57's right to communicate his healthcare wishes when he was unable to make or voice those decisions on his own. Findings: A review of Resident 57's Facesheet indicated the facility admitted the resident on 9/9/2023 with diagnoses including neurofibromatosis (a genetic disorder that typically causes benign tumors of the nerves and growths in other parts of the body, including the skin). A review of the clinical record and the Advance Directive Information indicated Resident 57 was provided information on an advance directive on 9/9/2023. A review of the Physician's Order dated 9/9/2023, indicated Resident 57 was to receive a social worker consult due to the resident's request to formulate an advance directive. A review of Resident 57'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-06 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 three sampled residents (Resident 59) was provided with a Notice of Medicare Non-Coverage (NOMNC - a notice that is provided to beneficiaries that indicates when their Medicare covered services are ending). This deficient practice had the potential to result in the resident not being informed of their coverage end date and not being able to exercise their right to file an appeal. Findings: A review of Resident 59's Facesheet Report indicated the resident was admitted to the facility on [DATE] for a urinary tract infection (UTI - infection that happens when bacteria enter the urinary system and infect the urinary tract). The Facesheet Report indicated Resident 59 was discharged home with home health on 7/10/2023. A review of Resident 59's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/9/2023, indicated the resident was cognitively (ability to think, understand, and reason) intact. The MDS further indicated Resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-06 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services 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 complete the Dialysis (the removing of waste, salt, and extra water to prevent build up in the body for residents who have loss of kidney function) Communication Record for one of 19 sampled residents (Resident 13). This deficient practice had a potential to place Resident 13 at risk for a delay in detecting complications related to dialysis including infections, pain, respiratory issues, and bleeding. Cross Reference: F867 Findings: A review of Resident 13's admission Record indicated the facility admitted the resident on 9/9/2023 for swollen feet, seizures (a sudden, uncontrolled burst of electrical activity in the brain), shortness of breath and cough with diagnoses including end stage renal disease (a medical condition in which a person's kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and a dependence on renal dialysis. A review of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-06 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 sampled residedent (Resident 111) was free of any significant medication errors (incorrect medication administration that could cause the resident discomfort or jeopardizes his/her health and safety) according to professional standards of practice by failing to: -Ensure Resident 111's had ordered parameters for (nifedipine [Procardia] and valsartan [Diovan] for hypertension). -Ensure Licensed Vocational Nurse 1 (LVN 1) did not administer nifedipine [Procardia] or valsartan [Diovan] to Resident 111 without parameters. This deficient practice had the potential to lead to uncontrolled blood pressure which could in turn cause cardiac arrest, stroke, and death. Findings: A review of Resident 111's Face sheet indicated the resident was admitted on [DATE] for right radial (forearm) artery (tubes of muscle that blood flows through) pseudoaneurysm (tear in the outer wall of the tubes of muscles). A review of Resident 111's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-06 · 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 all opened food items stored in the freezer was labeled with the name of the food item, open date, and expiration date. This deficient practice placed the 17 facility residents at risk for foodborne illness which could lead to serious infections and death. Findings: During an observation on 10/2/2023 at 8:55 AM with the Operations Manager of Food and Nutrition (OMFN) in the facility's freezer, an opened bag of meat patties was observed. During a concurrent interview the OMFN stated, The item is not in the proper area, the bag should be dated and put into a different container. Right now, it's unidentifiable. We date it to identify it and to know it's shelf life and when the food will expire. Right now, we don't know what it is. A review of the facility's policy and procedure titled, Purchasing, Receiving, and Storing of Food and Supplies - E.83200.024, revised 3/7/2023, indicated all foods held in refrigerated areas were required to be appropriately covered, clearly labeled, if not readily…

    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 · D2023-10-06 · tag F0838 — failed to assess facility resources and resident needs — isolated
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to conduct, develop, and revise annually a facility-wide assessment that included the resources needed to competently provide care to their residents. This deficient practice had a potential for the 17 facility residents to not receive comprehensive and specialized care placing them at risk for harm. Findings: During a telephone interview on 10/6/2023 at 10:29 AM, the [NAME] President (VP) 2, stated the facility did not have a facility assessment but had a Community Needs Assessment that addressed the community population the facility cared for. The VP 2 stated the Community Needs Assessment addressed the type of population the facility served, the cultural background, income level, health disparities, and education level. A review of the facility's Community Health Needs Assessment (CHNA) dated 2022, indicated the CHNA identified unmet health needs in the service area, provided information to select priorities for action, targeted geographical areas, and served as the basis for community benefit programs. The CHNA did not…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-06 · tag F0851 — isolated
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview record review, the facility failed to ensure their Payroll Based Journal (PBJ - information of the provider's daily staffing hours for the appropriate care of the residents) data had been submitted to the Center for Medicare and Medicaid Services (CMS) for two of four required quarters (1st fiscal quarter due 2/14/2023 and 2nd fiscal quarter due 5/15/2023) in 2023. This deficient practice had the potential to place the 17 facility residents at risk for delay in care, treatment, and services necessary to maintain physical and emotional wellbeing. Findings: A review of the facility's Certification and Survey Provider Enhanced Reporting system (CASPER: Shows the facility percentage and how the facility compares with other facilities in their state and in the nation) indicated no PBJ data had been submitted from 4/1/2023 through 6/30/2023. A review of CMS' website Staffing Data PBJ Submission website (https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission) indicated the deadlines for each reporting period were: The 1st fiscal quarter…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-06 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility's Quality Assessment and Assurance Committee (required to meet at least quarterly to identify issues and to develop and implement plans of action to correct identified deficiencies and to coordinate and evaluate activities to include performance improvement projects) failed to ensure a policy and procedure (a set of rules and/or guidelines that tell facility staff how to care for residents with specific needs) was in place for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). This deficient practice had the potential to inhibit dialysis residents in the facility from receiving high quality care and had the potential to create an unsafe environment for facility residents. Cross Reference: F698 Findings: A review of the facility's quality assurance and quality implementation plan (used to ensure services are meeting quality standards and assuring care reaches a certain level) indicated a policy and procedure for dialysis was not developed and available for review.…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
PIH HEALTH GOOD SAMARITAN HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 01/01/2020
ALVAREZ, ALEXIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 10/09/2017
ATWOOD, JIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 04/25/2005
BARENDSE, THURSOIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 02/08/2024
BATISTE, MELANIEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 10/21/2021
GOLDBERG, MARISSAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 10/01/2021
GREANEY, PETERIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/13/2018
HAMAR, HAMILTONIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 10/10/2016
KHORSANDI, MOEZIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 03/22/2024
KROG, SCOTTIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 12/13/2024
MEDRANO, DEBORAHIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 12/13/2024
MONROE, PATRICKIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 10/10/2016
ROTH, WILLIAMIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 03/01/2023
SARALIEV, TRACEAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 02/08/2024
SOUTHRON, SCOTTIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 12/13/2024
SYDA-LAWTON, REGINEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 12/13/2024
TREINEN, PAULIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 11/12/2019
WEAVER, CHARLOTTEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 10/10/2016
WEST, JAMESIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
WOODS, KENTONIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 02/28/2005
MAHALINGAMSHIVARAMAN, VIDHYASHANKARANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/12/2021
KPMG LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/18/2025
PIH HEALTH WHITTIER HOSPITALOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
COPPINGER, NOELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
LEONARD, ANNAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2022
NECKE, SHELLYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2022
PONCE, SUSANNEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
PRATT, ANDREWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/20/2023
RAHNEMA, GUDARSIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/02/2022
VAZQUEZ, CINDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2022
PIH HEALTH INCOrganizationADP OF THE SNFsince 01/01/2020

CMS files one row per role, so the 65 rows in the source record cover these 31 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

$3.5M
Net patient revenuemost recent cost report
-53.5%
Operating marginrevenue minus expenses
$5.4M
Related-party expense100% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 9%Other / private 91%

This home reported $5.4M paid to related parties — landlords or management companies under common ownership — equal to about 100% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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

$1,305per resident / day
operating cost
$39,663per month
≈ monthly operating cost
$850per 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 555927. 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 →

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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