Golden Merced Care Center
3170 M Street, Merced, CA 95340 · For profit - Limited Liability company · 121 certified beds · (209) 723-1056 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
- it has 2 actual-harm citations
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $83,538 in federal fines (most recent 2023-09-01)
- nursing-staff turnover (58%) runs well above the national median (45%)
- about 20% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 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 | 3 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 held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.6% | 10.2% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.0% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.3% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 7.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.1% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 11.8% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.7% | 13.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 88.5% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.8% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.1% | 10.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.9% | 12.0% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.0% | 93.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 31.9% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 28.7% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.90 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.78 | 1.57 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
42.9% 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 162 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.6% 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 79 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 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 64% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 42.9%CMS range 34.6–50.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.5%CMS range 6.8–13.3 | 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 | 50.6% | 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 | 50.6% | 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 | 43.0% | 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 | 99.3% | 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 | 98.0% | 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 | 95.5% | 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 | 0.7% | 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 | 2.9% | 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 | 7.7%CMS range 5.3–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 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 121 beds and averages 108.2 residents a day — about 89% occupied, or roughly 13 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 4.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 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 3.74 hrs/resident/day on weekends vs 4.21 on weekdays — 11% thinner on weekends. RN hours go from 0.44 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above 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 more than at the previous inspection — worsening. 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.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · Gcited before2023-09-01 · 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 provide adequate supervision (observation, oversight, and guidance of the individual by staff close enough to intervene and protect from harm) to prevent accidents for one of three sampled residents (Resident 1), when the facility failed to develop effective interventions for falls which occurred on 7/1/23, 7/4/23 and 7/8/23. These failures resulted in Resident 1 experiencing another fall on 7/8/23 with injuries of an Intracerebral Hemorrhage (bleeding inside the brain), right zygomatic (bones on upper side of the face that forms the cheek and part of the eye socket) fracture and right clavicle (collarbone) fracture along with pain and hospitalization. Findings: During a review of Resident 1's admission Record (AR), dated 7/18/23, the AR indicated, Resident 1 was admitted on [DATE] with diagnoses that included Dementia (loss of cognitive functioning, thinking remembering, and reasoning), Muscle Weakness, Difficulty in Walking and Other Specified…
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.
- Actual harm · Gcited before2019-04-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 22 sampled residents (Resident 76) were free from accidents and injury when Certified Nursing Assistant (CNA) 1 and CNA 6 used a mechanical lift sling (a hammock like cloth device used to hold the resident during transfer with a mechanical lift) past its manufactured recommended safe used by date of six months. The sling ripped during transfer and Resident 76 fell from the mechanical lift onto the floor and sustained a fracture (broken bone) of the right foot fifth toe. As a result of this failure, Resident 76 suffered a broken bone to the right foot fifth toe and was afraid to get out of bed in case of another fall. Findings: During a concurrent observation and interview with Resident 76, on 4/9/19, at 2:30 p.m., in Resident 76's room, Resident 76 laid in bed and stated, I stay in my bed because I fell from the sling way back. I can't remember the date I fell. During a review of the clinical record for Resident 76, the face…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-19 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 1 of three sampled residents were safe from physical abuse when Resident 1 slapped the face of Resident 2 twice. This failure resulted in Resident 2 experiencing blood in the mouth, pain, redness to the face, and mental anguish evidenced by weeping.During a review of Resident 1's admission Record (AR), dated 5/20/26, the AR indicated Resident 1 was an [AGE] year-old female admitted to the facility with diagnoses that included Alzheimer's Disease and dementia (progressive diseases of the brain affecting memory, mood, and judgement). During a review of Resident 1's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 4/30/26, the MDS indicated at Question GG 0170-K, that Resident 1 was able to walk about the facility independently. During a review of Resident 2's AR, dated 5/20/26, the AR indicated he was a [AGE] year-old male admitted to the facility with diagnoses that included bleeding in the brain, muscle weakness,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-01 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement adequate supervision, care planned interventions and Interdisciplinary Team's (IDT- a mandated group of healthcare professional including physicians, nurses, social workers, and therapists who collaborate to create and manage a comprehensive, individualized care plan for resident) recommended safety measures for 1 of 3 sampled residents (Resident [Res] 1) who was at high risk for falls. Resident 1 had four falls between 4/19/26 and 4/25/26, including an initial fall resulting in a right hip fracture (partial or complete break in a bone, often caused by high-force impact or stress) on 4/19/26, and two additional falls within four hours of readmission to the facility on 4/23/26 and another fall on 4/25/26. These failures resulted in pain and suffering, requiring Res 1 to be transferred back to emergency room (ER) via ambulance for evaluation on 4/23/25 and 4/25/26 and placed Res 1 at increased risk for more injuries and worsening of right hip…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe environment for one of four residents (Resident 3) when a Certified Nursing Assistant (CNA 2) failed to get the help and assistance of a second caregiver for a bed bath and linen change, as required by Resident 3's clinical documentation, and instead performed this activity without help. This failure resulted in Resident 3 falling from her bed to the floor, causing pain, anxiety, and a skin tear to her right wrist.During a review of the document titled SOC 341 dated, 3/30/26, the SOC 341 indicated that on 3/30/26, a charge nurse was called into [Resident 3's] room by CNA [2] at approximately 10 am related to a fall related to a bed bath. [Charge Nurse] assessed resident. Resident reported right arm skin tear on [top of] wrist. [Resident 3] was sent to the [Emergency Department] for further evaluation at 10:15 [a.m. CNA 2] immediately suspended pending investigation.During a review of the document titled 5 Day Summary, dated 4/3/26, the 5…
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 · D2025-11-19 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately identify and document all wounds present on readmission when the facility did not document the sacral wound identified in the hospital discharge summary and this wound was not reported to the wound care provider.This failure resulted in the resident's sacral wound not being identified, assessed, communicated, or treated following re-admission from the hospital.During a review of Resident 1's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 10/28/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes (T2DM-high blood sugar), anemia (lack of health red blood cells to transport oxygen, leading to fatigue and weakness), Chronic Atrial Fibrillation (the heart's irregular and rapid rhythm is continuous), Chronic Kidney…
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 before2025-07-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a safe environment and adequate supervision to prevent elopement ( a person left a place without anyone knowing or without permission) for 1 of 3 sampled residents (Resident 1), when the Wander Guard alarm system failed to activate when Resident 1 exited through a secured door and staff were not immediately alerted to the resident's departure.This failure resulted in Resident 1 leaving the facility unsupervised, placing Resident 1 at risk for serious injury, harm or death due to potential environmental hazards, including vehicular traffic.During a review of Resident 1's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the facility was free from accidents or hazards when one of three sampled residents (Resident 1) eloped (exited the facility without supervision or staff knowledge) from the facility when staff did not respond to a security alarm timely. This failure had the potential for Resident 1 to become lost, disoriented, physically injured from a fall or traffic collision, when he was found approximately 350 feet away from the facility. Findings: During a review of the facility document titled Subject: Unusual Occurrence, dated 7/9/25, the document indicated, On 7/8/25 at approximately 5:10 PM, [Resident 1] was seen ambulating in the south hallway. Approximately 10 minutes later he was reported to be in the [fast food restaurant] parking lot across the street from the back of the facility. Staff immediately responded and were able to guide [Resident 1] back to the facility. Nursing staff assessed [Resident 1] for any injuries and no injuries noted to him. [Security Alarm] system at the back door was in place and functioning.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) had elopement (when a resident leaves the facility, or a designated safe area within the facility, without proper authorization or supervision, which potentially endangers themselves) risk factors assessed when he was admitted to the facility. This failure resulted in Resident 1 eloping from the facility. Findings: During a review of Resident 1 ' s admission Record (AR), dated 6/11/25, the AR indicated he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (also known as a type of ' stroke ' which occurs when blood flow to a part of the brain is interrupted, leading to lack of blood supply and subsequent brain tissue death; symptoms can include sudden weakness or numbness on one side of the body, difficulty speaking or understanding speech, vision problems, dizziness, and loss of coordination), problems relate to life management difficulty, need for assistance with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the safety and security of the residents when 15 of 15 sliding glass doors (located in resident rooms that exited to the exterior of the building) were noted to be unsecured, with no system to alert staff if a person entered or exited the facility via these 15 doors. This failure resulted in one resident (Resident 1) eloping (the act of leaving facility premises, or enters an unsafe area, without facility knowledge and/or supervision) via one of the 15 unsecured sliding glass doors twice in one day, and after the second elopement was found by staff 0.6 miles from the facility in a confused state. This placed Resident 1 at significant risk for injury, including trauma from a traffic collision; and, resulted in the potential for other ambulatory residents to elope via the 15 unsecured doors in the facility, and the potential for unknown visitors to enter the facility via the 15 unsecured doors. Findings: During a review of Resident 1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-21 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents' food preferences for food brought in from the outside were met by warming food up when the facility microwave was removed from the resident food storage area and staff was instructed, they could no longer warm up food for residents. This failure resulted in residents' frustration and denial of food preferences not being warmed to acceptable temperatures for palatability. This failure resulted in residents not having the ability to warm up their frozen foods which lead to frustration and denial of food preferences not being warmed to acceptable temperatures for palatability. Findings: During a concurrent observation and interview on 3/17/25 at 11:33 a.m. with Resident 102 in Resident 102's room, a collection of canned and packaged food was on the top right side of Resident 102's counter. Resident 102 stated he has food brought in for evening snacks, or to eat if he did not want to eat what was on the menu from the kitchen.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-21 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 a baseline care plan (a document which specified goals, interventions, and monitoring strategies for patients) for three of nine sampled residents (Residents 221, 222, and 421) when: 1. Residents 221 and 222 did not have their baseline care plans completed within 48 hours of their admission to the facility This failure had the potential to cause Residents 221 and 222 to not have their respiratory care needs met 2. Resident 421 did not have his baseline care plan for a PICC (peripherally inserted central catheter- a thin, flexible tube that is inserted into a vein in the upper arm used to deliver medications directly into the heart) completed within 48 hours of his admission to the facility. This failure had the potential to cause Resident 421 to not have his care needs met potentially leading to poor patient outcomes (adverse effects) such as developing infections that could lead to a decline in health. Findings: 1. During a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · Ecited before2025-03-21 · 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 care plans for four of 12 sampled residents (Resident 71 and Resident 72, Resident 47 and Resident 223) when: 1. Resident 71 had an incomplete care plan for anxiety medication, and no care plan for Sertraline (anti-depressant medication) and Olanzapine (antipsychotic medication that alters brain chemistry to help reduce symptoms of the mind where there has been some loss of contact with reality). 2. Resident 72 did not have individualized care plans for Quetiapine (antipsychotic [class of drugs used to treat psychotic disorders] medication used to treat schizophrenia [a chronic mental health conditional characterized by significant disruptions in thought processes, perceptions, emotions and behavior] and bipolar disorder [chronic mental health condition characterized by extreme shifts in mood, energy and behavior]), Buspirone (medication used to treat anxiety disorders), and Lorazepam (anti-anxiety…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-21 · 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 observation, interview, and record review the facility failed to meet professional standards of quality for three of six sampled residents (Residents 4, 221, and 321) when 1. Resident 221's physician order for routine oxygen administration was not followed This failure had the potential to cause Resident 221 to experience negative health effects from lack of oxygen. 2. Resident 321 had an incorrect medication order for a Lidocaine Patch (medication that is used to relieve pain). This failure had the potential to result in incorrect placement of the Lidocaine Patch and the potential for the resident to experience ineffective pain control. 3. Resident 4's order for use of Pressure Reduction mattress for pressure redistribution was not being followed. This failure had the potential for Resident 4 to experience delayed healing of a wound, and to not receive necessary wound care. Findings: 1. During a review of Resident 221's admission Record (AR- a document that provides resident contact details, a brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-21 · 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
Based on observation, interview, and record review the facility failed to properly store medication in three of five medication carts and one of two medication storage rooms when: 1. South one medication cart contained: a. An unopened insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pen intended for refrigeration storage for Resident 56, and b. No open dates were placed on medications for Resident 78, Resident 99, Resident 322, Resident 222, and Resident 72. 2. South two medication cart contained: a. Six insulin pens with no open dates for Resident 68, Resident 53, Resident 5, and Resident 17. b. Expired medication for Resident 66, c. Four eye drop bottles did not have an open date, and d. Three respiratory medications did not have an open date. 3. North one medication cart contained: a. Discontinued medication for Resident 2, b. Two multi-dose (bottle or vial of liquid medication that contains more than one dose of medication) medications did not have open dates for Resident 15 and Resident 63, and c. One…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-21 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety when: 1. The facility had a clear plastic bag of what appeared to be frozen chicken with no labels or closure device, stored in one of two freezers. 2. The chest freezer did not have a thermometer to monitor the internal freezer temperature. 3. The cook did not take the temperature of the tray of meat loaf or the tray of au gratin potatoes during the lunch tray line service. These failures had the potential to place residents in the facility at risk for food born illness. Findings: 1. During a concurrent observation and interview on 3/17/25 at 9:52 a.m. with the District Manager of the kitchen (DMK), in one of two freezers, a clear plastic bag of what appeared to be frozen, and frost bitten (the surface of frozen food dries out and becomes leathery or discolored due to moisture loss), chicken had no labels or closure device on the bag. The DMK stated the meat should be in a labeled, airtight container for food freshness…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-21 · 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 4. During a review of Resident 371's AR, dated [DATE], the AR indicated, Resident 371 was admitted to the facility on [DATE] with diagnoses which included acute embolism and thrombosis of left lower extremity (a blood clot forming in a vein in the left leg, potentially blocking blood flow and leading to complications) and acquired absence of the left leg (surgical removal of the leg). During an observation on [DATE] at 4:20 p.m. in Resident 371's room, LVN 5 was changing resident 371's dressing. LVN 5 was not wearing a gown. LVN 5 stated Resident 371 had an amputated leg, and a wound had developed on it. LVN 5 stated Resident 371 was at risk for infection. LVN 5 stated Resident 371 was on enhanced barrier precautions (equipment such as gown and gloves, designed to reduce the transmission of multidrug-resistant organisms), and staff were required to wear a gown and gloves when entering the room to provide care. During an interview on [DATE] at 11:23 a.m. with the IP, the IP stated Resident 371 was on enhanced…
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 before2025-03-21 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 care in a manner that maintained dignity and respect for two of three sampled residents (Resident 25 and 47) when: 1.Resident 25's urinary catheter (flexible tube inserted into bladder to drain urine) bag was uncovered and visible to other residents and visitors. This failure had the potential to compromise Resident 25's dignity and privacy by exposing their foley catheter bag, leading to embarrassment or psychosocial harm. 2. A 20-minute time limit for morning Activities of Daily Living (ADL- tasks done on a daily basis to take care of your body, like bathing, brushing hair, brushing teeth, eating, and using the bathroom) care, for Resident 47, was implemented by using a timer, resulting in the resident feeling rushed and singled out. This failure resulted in the violation of resident 47's right to dignity leaving her feeling singled out by staff. Findings: 1. During a review of Resident 25's admission Record (AR) dated 3/19/25,…
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 · D2025-03-21 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a significant change of condition for Resident 42 when the resident was admitted to the facility on [DATE], was unable to make her needs known and be her own responsible party (RP- health care decision maker) Resident experienced a major improvement in mentation on 3/3/25 and no significant change of condition was completed. This failure had the potential to result in a lack of further improvement for Resident 72 when there were no updates in plan of care to reflect the change in mentation. Findings: During a record review of Resident 72's admission Record (AR) dated 3/20/25, the AR indicated Resident 72 was admitted into the facility on 2/17/25. The AR indicated, .Diagnosis Information . Cerebral Infarction (medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue) . metabolic encephalopathy (condition where brain ' s function is impaired due to an imbalance in the body ' s metabolism) .…
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 · D2025-03-21 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to administer parenteral fluids (Parenteral fluids administered by injection through the tissue and circulatory system) in accordance with professional standards of practice for two of three sampled residents (Resident 421 and 422), when: 1. Resident 421 was admitted to the facility on [DATE] with a peripherally inserted central catheter (PICC, tube that is inserted into a vein in the upper arm to the heart) for the purposes of administering intravenous (IV - through the vein) antibiotics (medicines that fight bacterial infections). The facility did not have an approved policy and procedure that followed the standards of practice to instruct and guide nurses on the care of the PICC line. Two of Two Registered Nurses (RN [RN 1 and RN 4]) and the Assistant Director of Nursing (ADON) were not trained and did not follow the standards of practice in the care of the PICC line. 2. Resident 422 was admitted to the facility on [DATE]/25 and a midline…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-10 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
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 an unknown number of residents' collective right to privacy was respected when Resident 3 frequently took photographs, with her smartphone, of an unknown number of residents without their consent. This failure resulted in an unknown number of residents having their privacy violated when Resident 1 frequently took their photographs without their consent. Findings: During a review of Resident 3's admission Record (AR) , dated 2/4/25, the AR indicated she was admitted to the facility in 2023 with diagnoses that included Paranoid Personality Disorder (a mental condition in which a person has a long-term pattern of distrust and suspicion of others). During a review of Resident 3's Care Plan (CP) , dated 1/20/25, the CP indicated, Resident 3 has a behavior of taking staff and other res[idents] pictures. Explain risks [versus] benefits of taking pictures of staff and other res[idents] without consent. During an interview on 1/21/25, at 2:10 pm., with the Social Services Director (SSD), the SSD stated Resident 3 has 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 before2024-11-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) had a care plan intervention in place by not placing a non-skid mat on the seat of her wheelchair, in an effort to reduce her frequent falls. This failure had the potential to result in an increased risk for falls for Resident 3. Findings: During a review of Resident 3's admission Record (AR) , dated 11/22/24, the AR indicated Resident was admitted to the facility on [DATE]. The AR indicated Resident 3 had diagnoses that included anemia (a condition where the body doesn't have enough healthy red blood cells to carry oxygen throughout the body, often resulting in weakness and feeling tired), muscle weakness, difficulty in walking, abnormalities in gait and mobility, and dementia (a chronic, progressive disease affecting mood, memory, and judgement). During a review of Resident 3's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool) , dated 10/10/24, the MDS indicated at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement physical interventions to reduce hazards and risks identified in their fall prevention program for 2 of 3 sampled residents (Resident 1 and Resident 2), and failed to ensure three of three sampled staff could not describe other key interventions of the fall prevention program when: 1. Resident 1 did not have non-skid socks (socks that have grips to prevent slipping when standing and walking) that were ordered by her physician as a fall prevention intervention. 2. Resident 2 had one transfer bar (bed rails attached to bed to aid resident when getting in and out of bed) attached to her bed when two transfer bars were ordered by her physician as a fall prevention intervention. 3. Three of three staff could not define what the 4 P's (1. Pain [address pain management] 2. Personal belongings [assure personal belongings are kept close to resident] 3. Personal care [assure residents ADL care is addressed] 4. Positioning [assure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #84) of 2 resident's food choices were provided per the resident's request. Specifically, the facility failed to honor Resident #84's preference for fried or poached eggs with their breakfast. Findings included: A facility policy titled, Food Preparation revised in 02/2023, revealed, 8. Only pasteurized egg products will be used for soft cooked egg items. An admission Record revealed the facility admitted Resident #84 on 01/18/2023. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/28/2024, revealed Resident #84 had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated Resident #84 was on a therapeutic diet and had no signs or symptoms of a swallowing disorder. Resident #84's Diet Requisition Form, dated 12/28/2023, revealed Resident #84 was on a regular, fortified diet with thin liquids. The form revealed staff completed the diet form due to a diet change. The option…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure the designated interdisciplinary team member obtained the hospice plan of care specific to 1 (Resident #27) of 2 sampled residents reviewed for hospice services. Findings included: A facility policy titled, Hospice Program, revised in 07/2017, indicated 1. Our facility has an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. The policy revealed, 9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: a. Determining the appropriate hospice plan of care. The policy revealed, 12. Our facility has designated [the facility's Director of Nursing] to coordinate care provided to the resident by our facility staff and the hospice staff. (Note: this individual is a member of the IDT [interdisciplinary team] with clinical and assessment skills who is operating within the state scope of practice…
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 before2023-10-17 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 were treated with respect and dignity for one of five sampled residents (Resident 1), when two Certified Nursing Assistants (CNA 3 and 4) did not stop providing care to the resident when the resident said to stop. This failure violated Resident 1 ' s right to be treated with respect and dignity and posed the risk to negatively impact Resident 1 ' s self-esteem. Findings: During a review of facility document Progress Notes, print dated 4/18/23, the progress note indicated Resident 1 was admitted to the facility on [DATE] and had diagnoses which included . MUSCLE WEAKNESS (GENERALIZED) (decreased strength of the muscles) . DIFFICULTY IN WALKING . During a review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 2/27/23, the MDS indicated, Resident 1 ' s Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) indicated a score of 15 (0-7 severe…
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 before2023-10-04 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 maintain infection and control practices to ensure a provision of a safe and sanitary environment for 103 out of 103 residents when: 1. One of two shower rooms had mold on the shower curtain. 2. Monitoring and tracking of deep cleaning for 52 of 52 resident rooms were not done as per policy. These failures had the potential to result in the development and transmission of communicable diseases, illness, and infections. Findings: During an interview on 9/7/23 at 8:55 a.m. with Resident 1, Resident 1 stated there was mold on the shower curtains in the shower room. Resident 1 stated he thought the mold was disgusting and made him feel like he wasn't really getting clean when he was showered. During a concurrent observation and interview on 9/7/23 at 9:15 a.m. with Certified Nurse Assistant (CNA) 2, in Shower room [ROOM NUMBER], a large amount of mold was observed on the bottom third of a shower curtain. CNA 2 stated there should be no mold…
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 · F2019-04-12 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct 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 ensure the facility assessment addressed the federal expectation to develop a water management program for the risk reduction of Legionella (a water borne bacteria which can cause life threatening pneumonia) and other water-borne pathogens (germs that cause disease) in accordance with CMS letter revision date 7/6/18. This failure resulted in the increased risk of not being prepared to address the risk of infections to residents for Legionella and/or other water-borne pathogens. Findings: During an interview with the Administrator (ADM), on 4/12/19, at 2:16 p.m., he stated he was aware of the facility's requirement to established a water management plan to reduce the risk of growth and spread of waterborne organisms (bacteria). During a concurrent interview and record review with the ADM, on 4/12/19 at 2:20 p.m., the facility document titled, Facility Assessment dated 2/1/19 did not have any information regarding the facility's need for a water management program. The ADM stated the water management plan was not addressed…
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 · F2019-04-12 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to establish and implement a comprehensive antibiotic (ATB) stewardship (program designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) and surveillance program to identify, track, and monitor resident antibiotic use when: 1. The Director of Staff Development (DSD) did not accurately monitor the use of antibiotic of resident infections on the monthly line listing surveillance logs for eight of eight sampled residents (Resident 74, Resident 92, Resident 79, Resident 6, Resident 34, Resident 91, Resident 48 and Resident 46). 2. The facility did not have documented monthly line listing surveillance logs for seven of 12 sampled months (June 2018, July 2018, August 2018, September 2018, October 2018, November 2018 and December 2018). These failures had the potential to result in the residents to be placed at risk for an adverse effect of antibiotics and/or develop an antibiotic-resistant (not effective to treat infection) organisms from unnecessary or inappropriate…
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 before2019-04-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure to store, prepare and serve food safely when: 1. An undated opened box of brown sugar, open bottle of ground spice pimiento, opened box of kosher salt were stored and ready for use in the condiments shelves in the kitchen. 2. An undated zip lock bag with 10 pieces of cooked pancake were stored and ready for use in the freezer 1 in the kitchen. 3. An undated and/or no use by date open boxes containing chicken, salami, pork [NAME] were stored and ready for use in freezer 2 in the kitchen. 4. Undated nutritional shakes were stored and ready for use in the kitchen walk in refrigerator and in the north nurse's station refrigerator. These failures to ensure effective dietetic service operations placed residents that received meal form the kitchen at risk for food borne illness and the growth of microorganisms. Findings: 1. During a concurrent observation and interview with the Certified Dietary Manager (CDM), on 4/9/19, at 8:25 a.m., in…
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 before2019-04-12 · 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 observation, interview and record review, the facility failed to provide services which met professional standards of quality when Licensed Nurse (LN) 1 administered a blood pressure (pressure of the blood with in the arteries and produced primarily by the contraction of the heart muscles) medication to Resident 37 without first checking Resident 37s heart rate and not following physicians order for one of two sampled residents. This failure had the potential risk for Resident 37 to receive medication with a possible side effect of a low heart rate. Finding: During a concurrent observation, interview and record review on 4/10/19, at 8:25 a.m., in Resident 37's room, LN 1 checked Resident 37's physicians order in the computer and read out loud, Metoprolol tartrate (medication use to treat high blood pressure) 50 mg (milligram) (dry unit of measurement) give 1 tablet by mouth two times a day, related to essential hypertension (high blood pressure) hold for SBP (Systolic Blood Pressure)(The top number is the systolic blood pressure, the highest level your blood pressure…
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 · D2019-04-12 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure one of six sampled Certified Nursing Assistants (CNA) 2 received appropriate competencies and skills set training when CNA 2 had not received competency training on orientation in order to provide safe use of the mechanical lift (a device used to transfer non ambulatory residents) and sling (a hammock like cloth device used to hold the resident during transfer with a mechanical lift) on residents. This failure had the potential to place residents requiring the use of the mechanical lift for transfers at risk for falls and injuries. Findings: During an interview with the Director of Staff Development (DSD), on 4/10/19, at 3:14 p.m., the DSD stated [Resident 76] experienced a fall while CNAs were using the mechanical lift to transfer resident from wheelchair to bed. DSD stated the mechanical sling ripped and Resident 76 fell onto the floor which resulted in Resident 76's broken right foot fifth toe. The DSD stated she saw the sling that was ripped during Resident 76's transfer. The DSD stated it was the CNA's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-04-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program when: 1. Registered Nurse (RN) 1 did not follow the facility policy and procedure titled Instillation of Eye Drops and administered eye drops without wearing gloves during the eye drop medication administration. 2. One whisk (wire kitchen utensil) was stored with the clean utensils on the cart in the kitchen. These failures had the potential for spread of infection and cause foodborne illness to residents. Findings: During a medication administration observation, on 4/10/19, at 8:22 a.m., on South station, RN 1 entered Resident 4's room and told Resident 4 she was giving her eye drops medication. RN 1 washed her hand in the sink then took the medicine eye drops and instilled to both eyes without wearing gloves. During an interview with the RN 1, on 4/10/19, at 8:33 a.m., she stated she washed her hand prior administering the eye drops and does not need to wear gloves unless it is antibiotic eye drops. During an interview with the Director 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.
“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
$83,538 in federal fines across 1 penalty.
- $83,538 — penalty dated 2023-09-01
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to GOLDEN SNF OPERATIONS — 7 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 | 3 of 5 | 2.9 | +0.1 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 3 of 5 | 3.4 | -0.4 vs chain |
| Quality measures | 3 of 5 | 2.9 | +0.1 vs chain |
The other 6 homes this chain runs (chain average 2.9★, 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 |
|---|---|---|---|---|
| CAFIVE OPERATIONS HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/01/2023 |
| CH CAFIVE HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 61% | since 03/01/2023 |
| MERCED SNF REALTY LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 03/01/2023 |
| SPIELMAN, SHIMON | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2023 |
| YENOWITZ, YITZCHOK | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2023 |
| CAFIVE OPCO MANAGER LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2023 |
| CAFIVE SNF CONSULTING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2023 |
| COUVE HEALTHCARE CONSULTING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/08/2025 |
| MERCED SNF OPERATIONS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2023 |
| VERITAS HEALTHCARE SOLUTIONS, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2025 |
| BARIAS, KAREN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/03/2025 |
| BOOTH, JEANETTE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2023 |
| EARL, STEVEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/03/2025 |
| MEADOR, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2023 |
| NOYES, DEBORAH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2023 |
| WITZCORP LLC | Organization | ADP OF THE SNF | — | since 03/01/2023 |
| HERZKA, YISROEL | Individual | ADP OF THE SNF | — | since 03/01/2023 |
CMS files one row per role, so the 33 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.
9 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 $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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
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 055988. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-21, 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.