Woodlands Healthcare Center
14966 Terreno De Flores Lane, Los Gatos, CA 95032 · For profit - Limited Liability company · 65 certified beds · (408) 356-8136 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- 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
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.8% | 10.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.7% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.7% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.5% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 17.9% | 9.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 11.8% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 19.3% | 10.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.8% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.5% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.1% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 17.0% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.30 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.47 | 1.57 | 1.80 | better |
‡ 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.
60.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 225 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 100 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 60.0%CMS range 53.1–67.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.5%CMS range 9.3–15.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 52.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 57.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 54.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 11.1%CMS range 7.9–14.5 | 7.1% | Oct 2023–Sep 2024 | worse than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.17 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 65 beds and averages 61.5 residents a day — about 95% occupied, or roughly 4 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 4.14 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.451 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.69 hrs/resident/day on weekends vs 4.33 on weekdays — 15% thinner on weekends. RN hours go from 0.87 to 0.75 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · D2025-09-19 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 free from unnecessary psychotropic medication (medications capable of affecting the minds, emotions, and behaviors) for one of three sampled resident (Resident 1) when: 1.There was no documented evidence of non-pharmacological (treatments and strategies that mange health conditions without using medications) approaches attempted before administered psychotropic medication lorazepam (used to treat for anxiety [persistent worry and fear about everyday situations]) to Resident 1;2.There was no documented evidence of side effects monitored for use of lorazepam (an unintended consequence of a medication, may be harmful) for Resident 1;3. There was no documented evidence of episodes of adequate behavior monitored for use of lorazepam for Resident 1.These above failures had the potential to place sampled resident at risk to receive unnecessary psychotropic medication.Findings:1.Review of Resident 1's face sheet (FS: a document that gives resident's information at a quick glance) indicated Resident 1 was admitted to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-19 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure to notify primary care physician (PCP) for refusal of blood tests (a laboratory analysis of a blood sample used to assess various aspects of resident's health) as ordered by the physician for one of three sampled resident (Resident 1) to meet professional standards.This failure had the potential to affect Resident 1's medical condition and well-being.Findings:Review of Resident 1's face sheet (FS: a document that gives resident's information at a quick glance) indicated, Resident 2 was admitted to facility on 7/9/2024.Review of Resident 1's medical diagnoses included diabetes type 2 (high blood sugar levels), chronic kidney (bean shaped body organ, filters waste and extra fluids from blood to produce urine) disease (a long term condition where the kidneys gradually lose tier ability to function properly), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow).Review of Resident 1's order summary report indicated basic metabolic (a blood test that measures several key…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-12 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and document review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) for 1 (Resident #51) of 2 sampled residents reviewed for nutrition. Findings included: The Centers for Medicare & Medicaid Services Long -Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual dated 10/2024, indicated, 03. Significant Change in Status Assessment The SCSA is a comprehensive assessment for a resident that must be completed when the IDT [interdisciplinary team] has determined that a resident meets the significant change guidelines for either major improvement or decline. Per the manual, A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Required interdisciplinary review and/or revision of the care plan. According 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.
- Potential for harm · Ecited before2024-12-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow it's Policy and Procedure titled Isolation-Categories of Transmission- Based Precautions, when the facility failed to provide evidence of implementing isolation precautions (process of creating barriers between people and germs to help prevent the spread of infectious microbes) during an outbreak of infectious gastrointestinal related illnesses for four of six sampled residents (Resident 1, Resident 2, Resident 3 & Resident 4). This failure had the potential to spread infectious disease to other residents and staff at the facility. Findings: During an interview on 12/2/24, at 9:35 a.m., with Infection Prevention Nurse (IP), IP stated, the care staff reported multiple residents with vomiting and diarrhea during the night shift in early October. IP stated, she became aware of the outbreak because it was documented in a change of condition report. IP stated, they began testing residents for C-diff (Clostridium difficile a bacterium that causes an infection of the colon, spread through physical contact) and Norovirus…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-13 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement comprehensive, person-centered, care plans for four of thirty-one residents investigated, (Residents 14, 41, 160 and 18) when: 1. Residents 14 and 41, the activity care plans did not specify the activities provided, there were no frequency of visits for the activities, and no measurable outcomes of the visits; 2. Resident 160, there were no interventions that were developed in the activity care plan, and 3. Resident 18, there was no care plan to address her excessive sleepiness issue. These failures had the potential to result in the residents, not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. Review of Resident 14's clinical record indicated, Resident 14 was an [AGE] year-old female with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), type 2 diabetes mellitus (adult onset, high blood sugar)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-13 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of 15 sampled residents (Residents 16, 18, and 21) when: 1. Resident 16, there were two duplicated insulin orders without parameters; 2. Resident 18, the treatment nurse did not label the dressing with the date, time, and initial and; 3. Resident 21, the licensed nurse did not refill her eye drop medicine on time and caused six missed treatments. These failures had the potential to negatively affect the residents' health and well-being. Findings: 1. A review of Resident 16's clinical record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (type 2 DM, adult onset high blood sugar) with diabetic neuropathy (the presence of symptoms or signs of peripheral nerve dysfunction in people with diabetes), type 2 diabetes mellitus with unspecified diabetic retinopathy (an eye condition that can cause…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-13 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 the residents received the necessary care and services for five of 15 residents (2, 8, 20, 22, and 37) when: 1. Licensed nurses did not follow the physician's order for pain medication based on the resident's pain level for Resident 2; 2. A bottle of gel hand sanitizer was on Resident 8's night stand in her room; 3. Licensed nurse did not follow the physician's order for oxygen supplement for Resident 20; 4. Licensed vocational nurse G (LVN G) did not know how to monitor Resident 22's AV fistula (a special connection that is made by joining a vein onto an artery, usually in the arm) and what to do if it was bleeding; and 5. LVN G did not know how to monitor the signs and symptoms if the pacemaker would malfunction for Resident 37. These failures had the potential to affect the residents' care and could jeopardize their health and well-being. Findings: 1. Review of Resident 2's admission Record indicated she was admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-13 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. unlabeled, discontinued, and expired medications were not removed from the medication carts to prevent medication errors; 2. medications were not labeled with full names or open date; 3. an insulin glargine injection pen (medication to lower blood sugar) did not have a patient-specific label; 4. two bottles of normal saline, and a cup with itching medication were left inside the resident's room. These deficient practices had the potential for residents, to receive medications with unsafe and reduced potency, from using them past their discard date and medication errors due to medications not being labeled or removed from active stock. Findings: 1. During an inspection of medication cart one on 10/9/2023 at 12:40 p.m., with the Nurse Supervisor (NS), the NS confirmed the following findings: a) an Enoxaparin sodium (anticoagulant medication) injection 40mg (milligram, a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-13 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure food palatability was maintained, when three of nine residents investigated, (Residents 3, 155 and 161), complained about the taste of the food being served. This failure had the potential to result in decreased food intake and weight loss, compromising the resident's nutritional status. Findings: 1. During a concurrent observation and interview of Resident 3 on 10/9/23 at 11:30 a.m., Resident 3 was laying in her bed, alert, oriented, calm and comfortable. She's on oxygen inhalation (therapy that provides extra air to breathe in) at 2 liters per minute via nasal cannula (device used to deliver supplemental or air to a resident). Resident 3 stated that she did not like the food, it had no flavor or taste. She said that she told the dietary manager in training (DMIT) already about it but nothing was done. Review of Resident 3's clinical record indicated, Resident 3 was an [AGE] year-old female, admitted to the facility last 12/19/22,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to ensure food was stored in accordance with professional standards for food safety when: 1. one 8-ounce water bottle brought by employee, was in Freezer #1; 2. one plastic bag with 7 frozen beef strips inside, had no used by date; and 3. the temperature of Refrigerator #2 was 50 degrees Fahrenheit (F, temperature scale). These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness for the 56 residents eating at the facility. Findings: 1. During an observation and interview with the dietary manager in training (DMIT) on 10/9/23 at 8:50 a.m., one 8-ounce water bottle brought by employee, was in Freezer #1. The DMIT stated that personal water bottle should have not put inside kitchen freezer. Review of the facility's undated policy, Employee meals, indicated, Policy: Food brought by employees from outside the facility should have not kept in the facility's refrigerator in the kitchen nor prepared or reheated in the facility's kitchen. Procedure: Employees bringing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · Ecited before2023-10-13 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for five of fifteen sampled residents (Residents 16,18, 161, 20, and 26) when: 1. Resident 16 and 18, the licensed nurses did not perform hand hygiene between glove changes during medication administration, 2. Resident 161, the licensed nurse did not disinfect the medication tray after touching potentially contaminated surfaces, 3. Resident 20, the filter of the oxygen concentrator was dusty and 4. for Resident 26, Certified Nursing Assistant C (CNA C) walked out of Resident 26's room with gloves on her hands. These failures could result in the spread of infection and cross-contamination that could affect the 61 residents in the facility. Findings: 1. During a medication administration observation on 10/11/2023 at 11:45 a.m., with licensed vocational nurse LVN A in front of Resident 16's room, LVN A was observed performing multitask and changing gloves between tasks but did not wash or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-13 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet the needs of two residents (13 and 20) when they were simultaneously administered two medications with drug-to-drug interaction (situation in which a drug affects the activity of another drug when both are administered together). This interaction may decrease the therapeutic effect of the medications for the residents. Findings: Review of Resident 13's admission Record indicated, she was admitted to the facility on [DATE] with anemia (a low number of red blood cells) diagnosis. Review of Resident 13's clinical record indicated, she had physician orders for ferrous sulfate (a supplement used to prevent or treat low blood iron levels) 220 milligrams (mg, a metric unit of mass) per 5 milliliters (ml, a metric unit of volume) daily at 9 a.m., started on 7/21/23, and for calcium carbonate (a medication used to prevent or treat low blood calcium levels) 500 mg, give two tablets daily at 9 a.m., started on 7/21/23. Thus, since 7/21/23, ferrous sulfate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-13 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and policy review, the facility failed to follow its policy and procedure on foods brought by resident's family for two of fifteen residents (11 and 21), when an expired 8-ounce bottle of Glucerna (a nutritional supplement) and an expired box of sesame cookie rolls were on Resident 11's and Resident 21's night stands. These failures had the potential to result, for Resident 11 and Resident 21, to develop foodborne illness. Findings: During an observation and interview with licensed vocational nurse B (LVN B) on 10/9/23 at 12:03 p.m., an 8-ounce bottle of Glucerna was found on top of Resident 11's night stand with an expiration date of 7/1/23. LVN B stated, the Glucerna bottle had already expired, and it should have not kept inside the resident room. During an interview with the director of nursing (DON) on 10/13/23 at 2:34 p.m., she stated the expired Glucerna bottle should have not in Resident 11's room on her night stand even though it was brought in by Resident 11's family. During an observation and interview with LVN B on 10/9/23 at 12:24 p.m., a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-17 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of one of 3 residents (Resident 1) when Resident 1 did not receive her Hydromorphone (a potent controlled medication for pain) Hydrochloride (HCL - acid salt mixed in the medication) in timely manner as prescribed by the physician. This failure had the potential to result in unnecessary pain. Findings: Review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility with diagnoses including aftercare following joint replacement surgery, presence of left artificial knee joint, other chronic pain and dorsalgia (physical discomfort occurring anywhere on the spine or back, ranging from mild to disabling). Review of Resident 1's clinical record titled, Order Summary Report, dated 05/17/2023, indicated, HYDROmorphone HCL Oral Tablet 2 MG (milligrams - unit of measurement) Give 4 mg by mouth every 3 hours as needed for severe pain 7-10. The medication was ordered on 5/14/2023. 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.
- Potential for harm · Fcited before2021-12-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, the facility failed to store and prepare food under sanitary conditions when: 1. There was outdated food in the kitchen refrigerator; 2. There was water leaking from a ceiling vent onto the kitchen freezer; 3. There was a brown substance inside the ice machine; and 4. Dietary staff used expired test strips and improper technique when testing the kitchen surface sanitizer (solution used to kill microorganisms on kitchen surfaces). These failures had the potential to result in foodborne illness (illness resulting from contaminated food) throughout the facility. Findings: 1. During an observation on 12/13/2021 at 8:58 a.m., there was a plastic container of strawberries in one of the kitchen refrigerators. The container was labeled, Use by 12/11. During a concurrent interview with [NAME] A, she confirmed the strawberries in the refrigerator were outdated. The facility's 2018 document, titled Produce Storage Guidelines, indicated strawberries can be stored in the refrigerator for two to three days. 2. During an observation on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-12-17 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for five of 15 sampled residents (Residents 55, 35, 58, 6 and 12) when: 1. Nursing staff provided ice chips to Resident 55, who had a strict nothing by mouth (NPO, no food or drinks) doctor's order; 2. Nursing staff did not provide Resident 35's right hand carrot orthosis (device used to prevent further stiffening of the hand) as ordered; 3. Nursing staff did not provide a left fifth finger splint to Resident 58 as ordered; 4. For Resident 6, the charge nurse signed for a treatment that was provided by the treatment nurse; and 5. The physical therapist did not use a gait belt (device attached to the resident to assist with transferring and walking) while walking Resident 12 when indicated. These failures had the potential to affect the residents' care and jeopardize their health and well-being. Findings: 1. A review of Resident 55's clinical record indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-12-17 · tag F0880 — failed to prevent and control infections — patternProvide 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 practices when: 1. Certified nursing assistant L (CNA L) did not perform the COVID-19 (infectious disease caused by SARS-Cov-2 virus) healthcare professional screening prior to entering the facility; 2. The housekeeper (HK) and CNA J did not perform hand hygiene in between tasks; 3. The treatment nurse (TN) did not perform hand hygiene in between tasks and practiced double gloving (wearing of inner and outer gloves) during wound care; and 4. The business office manager (BOM) did not perform the COVID-19 screening assessment prior to entering the facility. These failures had the potential to compromise resident's health and safety in the facility. Findings: 1. During an observation and interview on 12/13/2021 at 8:55 a.m., while in the facility's lobby, CNA L went inside the facility, checked his temperature, but did not perform the employee COVID-19 screening prior to entering the facility. CNA L said he started orientation 3 days ago. During an interview and record review with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-17 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to assess if the resident was safe to self-administer medications for one of 15 sampled residents (Resident 6). A resident may only self-administer medications after the IDT (Inter Disciplinary Team) has determined which medications may be self-administered. This failure had the potential to result in unsafe medication administration, and could have allowed other residents to access unlocked medications. Findings: During an observation on 12/13/21 at 10:00 a.m., an Aquaphor cream jar (a topical ointment for dry skin) and other personal cleaning products were found on Resident 6's bedside nightstand. During a follow-up observation on 12/14/21 at 3:51 p.m., multiple medications were found on Resident 6's bedside nightstand and over-bed table. During an interview on 12/14/21 at 4:00 p.m., with licensed vocational nurse H (LVN H) , she stated the medications found at Resident 6's bedside were Nystatin powder (a topical powder for fungal infection) and Biofreeze (a topical ointment for pain). LVN H further 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.
- Potential for harm · D2021-12-17 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's code status (instructions on what to do if the resident has no pulse and stops breathing) was clearly indicated in the medical record for one of 15 sampled residents (Resident 24). This failure had the potential to result in the facility not acting in accordance with Resident 24's wishes in the event of an emergency. Findings: Review of Resident 24's medical record indicated he was admitted on [DATE]. Resident 24's face sheet (document with basic information) did not specify his code status. The area of the face sheet titled Advance Directive [resident's wishes regarding medical treatment] was blank. Resident 24's undated Physician Orders for Life Sustaining Treatment (POLST, document that specifies the medical treatments the resident wants to receive during serious illness) was reviewed. Most of the POLST was blank, including the section regarding what to do if the resident had no pulse or stopped breathing. During an interview and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 interview and record review, the facility failed to provide services to promote healing of pressure ulcers (damage to the skin and underlying tissue as a result of prolonged pressure) for one of 15 sampled residents (Resident 11) when: 1. The facility did not obtain treatment orders for the resident's multiple pressure ulcers in a timely manner; 2. There was no documentation indicating the facility provided treatments for the resident's multiple pressure ulcers; and 3. The facility did not develop care plans to address the resident's multiple pressure ulcers. These failures had the potential to result in worsening pressure ulcers and the development of new pressure ulcers for Resident 11. Findings: Review of Resident 11's medical record indicated she was readmitted to the facility on [DATE]. Review of Resident 11's Baseline Admission/readmission Screen document, dated 12/12/2021, indicated Resident 11 had one pressure ulcer on her left heel, one on her right heel, four on her back, one on her sacrum…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement appropriate new interventions after a fall for one of 15 sampled residents (Resident 9). This failure had the potential to result in Resident 9 experiencing further falls and injury. Findings: Review of Resident 9's medical record indicated she was admitted on [DATE] and had the diagnoses of disorientation (a state of mental confusion), glaucoma (condition that causes gradual loss of sight), and abnormalities of gait (manner of walking) and mobility. Review of Resident 9's Minimum Data Sets (MDS, assessment tools) dated 9/14/2020, 9/30/2020 and 12/31/2020, indicated she had brief interview for mental status (BIMS) scores ranging from 5 to 11 (these scores indicate moderate to severe cognitive impairment). Review of Resident 9's care plan, dated 9/4/2020, indicated she was at high risk for falls and injury related to use of psychotropic medications (medications used to treat mental disorders). The care plan included interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
2. A review of Resident 12's clinical record indicated the resident was admitted with a diagnosis of acute respiratory failure with hypoxia. A review of Resident 12's physician order, dated 10/28/21, indicated Change humidifier bottle every week, every Sunday and as needed (PRN) when empty. During observations on 12/13/21 at 9:17 a.m. and on 9/14/21 at 1:10 p.m., Resident 12 was in bed, with oxygen at six LPM and no humidifier bottle connected to the oxygen concentrator. During a concurrent interview and record review on 12/15/21 at 10:40 a.m., the nurse supervisor (NS) reviewed Resident 12's physician order and confirmed the resident had an order for humidifier. During an interview on 12/16/21 at 12:50 p.m., the DON confirmed Resident 12 did not have an oxygen humidifier when she did her rounds on 12/15/21. Review of the facility's policy titled Oxygen Administration, dated 2/2014, indicated Steps in the Procedure: Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Based on observation, interview and record review, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-17 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to document administration of controlled medications (medications controlled by the government because they may be abused or cause addiction) on the controlled medication accountability sheet (count sheet) for three residents (Residents 6, 11 and 16). This failure compromised the facility's ability to ensure accurate administration of medications. Findings: Review of Resident 11's controlled medication accountability sheet on 12/14/21, indicated the remaining count of Pregabalin (nerve pain medication) 50 milligrams (mg, unit dose of measurement) was 17, but the medication stock count was 16. During an interview with licensed vocational nurse C (LVN C) on 12/14/21 at 10:45 a.m., she stated she gave one dose of Pregabalin 50 mg around 10:00 a.m., today, but did not document it yet. The LVN stated she should have documented it right away. Review of Resident 16's controlled medication accountability sheet on 12/14/21, indicated the remaining count of Metronidazole (antibiotics) 500 mg was 20, but the medication stock count was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-17 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 of 15 sampled residents (Resident 50) had the appropriate indication for the use of Nuedexta (medication for pseudobulbar affect). This failure put the resident at risk for receiving unnecessary medication. Findings: Review of Resident 50's clinical record indicated she had the diagnosis of unspecified psychosis (a mental disorder characterized by a disconnection from reality) and did not have the diagnosis of pseudobulbar affect (a nervous system disorder that causes inappropriate involuntary laughing and crying). Review of Resident 50's physician orders, dated 12/04/21, indicated Nuedexta 20-10 milligrams (mg, unit of dose measurement) by mouth two times a day for psychosis manifested by hallucination. During an interview and concurrent record review with the director of nursing (DON) on 12/15/21 at 2:56 p.m., Resident 50's Consultant pharmacist's medication regimen review, dated 10/6/21, indicated Clarify diagnosis for use of Nuedexta. This is only approved for pseudobulbar affect. The DON stated she was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-17 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 one of 15 sampled residents (Resident 50) was free of unnecessary psychotropic medications (medications capable of affecting the mind, emotions and behavior) when there was no documentation of monitoring for the specific target behavior of paranoid ideation. This failure resulted in lack of adequate behavior monitoring and had the potential for the resident to receive unnecessary psychotropic medications. Findings: Review of Resident 50's clinical record indicated she had the diagnosis of unspecified psychosis (a mental disorder characterized by a disconnection from reality). Review of Resident 50's physician orders, dated 12/4/21, indicated Risperidone [medication for mental/mood disorder] 0.5 milligrams [mg, unit of dose measurement] by mouth at bedtime for psychosis manifested by paranoid ideation. The orders also indicated, Monitor episodes of paranoid ideation and document number of episode(s) every shift. During an interview and concurrent record review with the director of nursing (DON) on 12/15/21 at 2:56…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-17 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure: 1. Five expired medications were properly discarded and not stored in the medication cart and/or the medication refrigerator and, 2. Safe storage of medications for two of two treatment carts. These deficient practices had the potential for unsafe and ineffective use of medications being used past the expiration date and risk the misuse of medications because they were unlabeled or improperly labeled. Findings: 1. During a concurrent medication refrigerator inspection for Station J and interview with the director of nursing (DON) on 12/13/21 at 3:45 p.m., the surveyor observed one opened Afluria Quadrivalent (influenza vaccine) 5ml multi dose vial (about half dose remaining) with no open date. The included full prescribing information for the medication indicated, Once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days. The DON verified there was no open date and no proof that the medication was not expired. The DON stated she would consider it as expired.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ASPEN SKILLED HEALTHCARE — 35 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.7 | +1.3 vs chain |
| Health inspection | 5 of 5 | 3.1 | +1.9 vs chain |
| Staffing | 3 of 5 | 3.9 | -0.9 vs chain |
| Quality measures | 3 of 5 | 4.5 | -1.5 vs chain |
The other 34 homes this chain runs (chain average 3.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ALGT,LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 11/01/2009 |
| SEQUOIA HEALTHCARE GROUP LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 01/01/2023 |
| BRADSHAW, PETER | Individual | INDIRECT OWNERSHIP INTEREST | — | since 07/07/2023 |
| ELSNER, ERIC | Individual | INDIRECT OWNERSHIP INTEREST | — | since 11/01/2009 |
| KIRKWOOD, JARED | Individual | INDIRECT OWNERSHIP INTEREST | — | since 01/01/2019 |
| ORGILL, CRAIG | Individual | INDIRECT OWNERSHIP INTEREST | — | since 01/01/2019 |
| PARTI, RAJESH | Individual | INDIRECT OWNERSHIP INTEREST | — | since 11/01/2009 |
| PARTI, SHRUTY | Individual | INDIRECT OWNERSHIP INTEREST | — | since 11/01/2009 |
| PAXMAN, MARCUS | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 01/01/2023 |
| RAWE, COLTON | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| CHI, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/08/2024 |
| OCAMPO, JOSALYN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/20/2019 |
| RAWE, CONNER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/29/2019 |
| BRADSHAW, JEFFREY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | — | since 01/01/2023 |
| ASPEN HEALTHCARE SERVICES LLC | Organization | ADP OF THE SNF | — | since 01/01/2023 |
| EAST WEST BANK | Organization | ADP OF THE SNF | — | since 11/01/2009 |
| J. CYRIL JOHNSON INVESTMENTS CORP | Organization | ADP OF THE SNF | — | since 04/22/2026 |
| MOSS ADAMS LLP | Organization | ADP OF THE SNF | — | since 11/01/2009 |
| WELLS FARGO BANK, NATIONAL ASSOCAITION | Organization | ADP OF THE SNF | — | since 11/01/2009 |
| JURADO, FRANK | Individual | ADP OF THE SNF | — | since 01/01/2023 |
CMS files one row per role, so the 30 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $737K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055517. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-12, 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 →
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