Modesto Post Acute Center
159 E. Orangeburg Avenue, Modesto, CA 95350 · For profit - Limited Liability company · 99 certified beds · (209) 526-2811 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (29) — 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
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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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 11.0% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.0% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 10.9% | 7.3% | 6.5% | worse |
| 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 | 1.3% | 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 | 26.3% | 13.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 86.6% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.5% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.7% | 10.2% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.0% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.1% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 17.2% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 15.5% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.73 | 2.25 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.81 | 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.
51.3% 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 129 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.7% 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 76 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 0.40 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 24% 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 | 51.3%CMS range 40.9–61.2 | 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 | 9.2%CMS range 6.5–11.9 | 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 | 48.7% | 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 | 50.0% | 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 | 50.0% | 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 | 90.8% | 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 | 90.6% | 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 | 0.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.2%CMS range 3.2–9.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 99 beds and averages 95.3 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. 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 4.02 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.51 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 4.14 on weekdays — 9% thinner on weekends. RN hours go from 0.94 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% 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 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.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · Gcited before2024-11-12 · 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 honor six out of six sampled residents ' (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) rights when they all were given written notices they would have to move into different rooms in the facility with no existing reason to do so, despite some of the residents having resided in their rooms for several years. This failure resulted in: 1. The potential for more than minimal harm for Resident 1, Resident 2, Resident 3, Resident 5, and Resident 6 when their collective right to a respectful and dignified existence was not honored by failing to allow all six residents ' rights to self-determination, affecting their right to a respectful and dignified environment, by not allowing them to remain in their rooms that had been their home for years which the residents strongly objected to, and, 2. Actual harm to Resident 4 when her mood and behavior changed, exhibiting increased irritability, depression, sadness, loss of health 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 · F2026-03-20 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
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 garbage storage area was maintained in safe and sanitary conditions when:1. Grayish fluids from the sewer and thick yellowish drainage from the grease trap were draining creating a pool into the driveway on 3/17/26.2. Two of the three garbage bins did not have a lid and were open to air on 3/18/26.These failures had the potential for unwanted pest ((any organism-insect, rodent, or microbe-those damages structures or threatens human health) which could have led to disease transmission causing foodborne illness (results from eating food contaminated with germs [bacteria, viruses, parasites] or toxins) leading to hospitalization for 98 residents, vendors, guests and staff.Findings:During an observation on 3/17/26 at 10:02 a.m. in the backway alley, a water outlet had grayish fluids gushing out and a grease trap to the right, had thick yellowish fluids flowing down gathering with the grayish fluids creating a pool in front of the garbage bins in the driveway. There was a musty, rotten, foul odor resembling…
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 · F2026-03-20 · 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 promote and implement an antibiotic (ATB) stewardship and surveillance program (ATBS- designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) for the use of antibiotics when:Infection screening evaluations (ISE-completed before starting antibiotics to ensure the medication is necessary, effective, and targeted) were not completed before residents started antibiotics.Antibiotics discontinued after initiation, for not meeting infection screening evaluation criteria, were not included in antibiotic stewardship data review or monitoring for 2/2026.This failure resulted in the administration of unnecessary and inappropriate antibiotic use, as well as inaccurate monitoring of antibiotic use which could lead to antibiotic-resistant organisms and inaccurate data monitoring and reporting.During a concurrent interview and record review on 3/20/26 at 12:54 p.m. with the Infection Preventionist (IP), the facility's document titled, Infection Prevention and Control Surveillance Log…
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 · E2026-03-20 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared safely in accordance with professional standards of food service safety for 95 out of 98 residents receiving food at the facility when:1. An open bag of potato chips inside a zip lock bag did not have a use by (a crucial safety indicator found on perishable foods like meats and salads, marking when it is no longer safe to eat, even if it appears fine) date.2. The food preparation sink did not have an air gap (space between the end of sink pipe and top of sink to prevent backflow). These failures had the potential to result in the serving of expired, spoiled, or contaminated food and items which could result in foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) to 95 residents receiving food from the kitchen.Findings:During an observation current observation on 3/17/26 at 9:31 a.m. in the storage room with the Certified Dietary Manger (CDM), a zip lock bag containing an open bag of potato chip was not labeled with a use by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-20 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of 10 sampled residents (Resident 74 and Resident 75) were informed, in advance, by the physician or other practitioner, of the risks and benefits of proposed treatment when:1. Resident 74 did not have a signed physician informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) prior to receiving psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications Mirtazapine (a drug used to treat depression) and buspirone (a medication used to treat generalized anxiety disorder).2. Resident 75 had an order for [Brand name for lorazepam] (psychotropic, anti-anxiety medication used to alter mood and behavior) as needed and the informed consent was not signed by the provider.These failures resulted in the violation of Resident 74 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 · D2026-03-20 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a homelike environment was maintained for one of eight sampled residents (Res 2) when the Resident's Clothing and Possession Inventory on admission (RCPIA-a sheet used for inventorying residents' personal items) was not updated to reflect current items in the closet on 3/20/26.This failure resulted in Res 2's personal items being inaccurately inventoried, which could lead to clothing and items being unaccounted for when missing and has the potential to cause upset and inconvenience for residents and their families.Findings:During a review of Res 2' s admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/20/26, the AR indicated Res 2 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), acute kidney failure (sudden decrease in kidney function occurring over hours or days, causing waste buildup,…
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 · D2026-03-20 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise and implement, in a timely manner, a person-centered comprehensive care plan (CP- a personalized, written document detailing an individual's health needs, goals, and the specific services or support required to manage them) for two of eight residents (Res 2 and Res 70) when:1. Res 2 's had continued CP' for not swallowing and pocketing (the act of holding food in the mouth) food when returned from the hospital with a percutaneous endoscopic gastrostomy (PEG tube-a feeding tube inserted through the abdomen into the stomach) and was NPO (nothing by mouth) on 12/22/24.2. Res 70's had a continued short term care plan to observe for dark amber urine past the 48-to-72-hour timeframe.These failures had the potential to result in the goals and care interventions for Res 2 and Res 70 not being resident-centered and failing to adequately meet their needs.Findings:1.During an interview on 3/17/26 at 2:47 p.m. with Family Member (FM) 1, FM 1 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 · Dcited before2026-03-20 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure professional standards of practice for two of six sampled residents (Resident 87 and 104) when:1.Resident 87 was administered amiodarone (blood pressure [force of blood pushing against artery walls] medication used to treat irregular heart rhythms), four times, outside of ordered parameters. This failure resulted in Resident 87 receiving amiodarone on 2/3/26, 2/5/26, 2/13/26 and 3/11/26 when it should have been held, according to order parameters, which could lead to decreased blood pressure, cardiac distress and adverse effects. 2.The facility failed to ensure a physician order was received for an Incentive Spirometer (IS - handheld plastic device that acts as exercise equipment for the lungs, helping take slow, deep breaths to keep them active and clear after surgery or illness), for one of nine residents (Resident 104).This failure had the potential to delay strengthening of respiratory muscles, lung capacity, and clearing 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 · D2026-03-20 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure vegetables were prepared to conserve appearance and palpability for three of eight sampled residents (Res 25, Res 60 and Res 69) when the Italian blend vegetables with carrots and squashes were soft and mushy, and string beans were split in half with bean pods exposed for lunch served on 3/19/26.,This failure had the potential to result in vegetables not being consumed for Res 25, Res 60 and Res 69 and not meeting their recommended daily allowance (RDA- the average daily dietary intake level sufficient to meet the nutrient requirements of nearly all (97.5 percent) healthy) leading to malnutrition (a dangerous imbalance between the nutrients the body needs and those it receives).Findings:During a review of Res's 25 admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/20/26, the AR indicated Res 25 was admitted to the facility on [DATE]…
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 before2026-03-20 · 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 establish and maintain an effective infection prevention and control program for one of four sampled residents (Resident 103) when Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) was not worn during care for Resident 103 who was on Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities). This failure placed Resident 103 at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect) and infection (an invasion of the body by germs that cause disease).Findings:During an observation on 3/17/26 at 11:19 a.m. outside Resident 103's room, an EBP sign was observed on Resident 103's door, and a green sticker 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 · D2025-05-28 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 report an injury of unknown origin for one of three sampled residents (Resident 1) when Resident 1 was noted to have pain, bruising, and swelling to her right hand and wrist; and discoloration to her left wrist. This failure resulted in Resident 1's injuries of an unknown source to not be investigated, placing Resident 1 at potential risk for harm and/or abuse, and delayed medical intervention. Findings: During a review of Resident 1's admission Record (AR) , dated 5/20/25, the AR indicated Resident 1 was a [AGE] year-old female with medical diagnoses that included dementia (progressive disease of the brain affecting memory, judgement, and mood), schizophrenia (mental illness affecting perceptions of reality), disorders of the bone, other disorders of the brain, disorientation, need for assistance with personal care, bipolar disorder (mental illness with extreme shifts in mood, behavior, and energy), muscle weakness, and others. During a review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2024-10-01 · tag F0624 — isolatedPrepare residents for a safe transfer or discharge from the nursing home.
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 follow its transfer and discharge policy and procedure for one of three sampled residents (Resident 1) when the facility failed to comply with the legal requirements to provide Resident 1 with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. This failure had the potential to result in Resident 1's unsafe discharge and increased likelihood of preventable re-admissions. Findings: During a concurrent observation and interview on 10/1/24 at 1:20 p.m. with Resident 1 outside on the patio, Resident 1 was sitting in her wheelchair playing a card game on an electronic tablet. Resident 1 stated, she was given a 30-day notice to be discharged because she had not complied with the smoking policy that was recently enforced. Resident 1 stated, her mother called the ombudsman for assistance after the 30-day notice was issued to Resident 1. During a telephone interview on 10/3/24 at 8:41 a.m. with Social Services…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-15 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
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 a significant medication error did not occur for 1 (Resident #46) of 5 residents reviewed for unnecessary medications. Specifically, facility staff failed to follow a physician's order to hold midodrine hydrochloride (a medication used to treat low blood pressure) when the resident's systolic blood pressure (SBP, the top number in a blood pressure reading) was greater than 130 millimeters of mercury (mmHg) and failed to only administer losartan potassium (a medication used to treat high blood pressure) when the resident's SBP was greater than 130 mmHg. Findings included: A facility policy titled, Administering Medications, revised 04/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. The policy indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy indicated, 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies 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 before2024-08-15 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility policy review, the facility failed to ensure residents rooms measured at least 80 square (sq) feet (ft) per resident in 26 (Rooms 101-108, Rooms 115-124, and Rooms 130-137) of 36 resident rooms in the facility. Findings included: A facility policy titled, Bedrooms, revised 05/2017, revealed, 1. Bedrooms accommodate no more than two residents at a time. 2. Bedrooms measure at least 80 square feet per resident in double rooms, and at least 100 square feet of space in single rooms. The Client Accommodations Analysis, completed by the Administrator and dated 08/15/2024 revealed: - In room [ROOM NUMBER], the total floor area measured 229.99 sq ft and three beds occupied the room, which yielded 76.66 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 229.99 sq ft and three beds occupied the room, which yielded 76.66 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 229.99 sq ft and three…
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 · D2024-08-15 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, facility document review, and facility policy review, the facility failed to provide 1 (Resident #40) of 1 sampled resident reviewed for preadmission screening and resident review (PASARR) with the recommended specialized services identified by the resident's PASAR) Level II. Specifically, the PASARR determination report dated 04/18/2024 for Resident #40 recommended specialized services of psychotherapy/counseling which were not provided by the facility. Findings included: A facility policy titled, admission Criteria, revised 03/2019, indicated, c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. An admission Record revealed the facility admitted Resident #40 on 03/02/2017. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder and post-traumatic stress disorder. A quarterly…
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 · D2024-08-15 · 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 facility policy review, the facility failed to ensure windows on the secure unit were locked and secure for 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 9 residents' rooms located on the secure unit. Specifically, room [ROOM NUMBER] and room [ROOM NUMBER] had missing and/or damaged window screens and no locking mechanism to prevent the windows from opening fully. Findings included: A facility policy titled, Safety and Supervision of Residents, revised 07/2017, revealed, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy indicated, 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.…
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 · D2024-08-15 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, facility document review, and facility policy review, the facility failed to obtain psychiatric consultation as ordered for 1 (Resident #58) of 19 sampled residents. Findings included: A facility policy titled, Physician Services, revised 02/2021, indicated, 8. Consultative services are made available from community-based consultants or from a local hospital or medical center. An admission Record revealed the facility readmitted Resident #58 on 07/15/2024. According to the admission Record, the resident had a medical history that included diagnoses of vascular dementia, moderate with other behavioral disturbance and depression. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/21/2024, revealed Resident #58 had a Staff Assessment for Mental Status (SAMS), which indicated the resident had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #58 had physical and behavioral symptoms directed toward others and behaviors not directed toward others one to three days…
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 · D2024-08-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure nursing staff did not document the monitoring of peripheral intravenous (IV) site when the resident no longer had the IV because it had been removed for 1 (Resident #297) of 19 sampled residents. Findings included: A facility policy titled, Medication and Treatment Orders, revised 07/2016, revealed, Orders for medications and treatments will be consistent with principles of safe and effective order writing. An admission Record revealed the facility admitted Resident #297 on 07/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of adult failure to thrive and liver disease. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/02/2024, revealed Resident #297 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident had active diagnoses to include malnutrition and failure to thrive. Resident #297's care plan included a focus area,…
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 before2024-08-15 · 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 facility policy review, the facility failed to ensure facility staff used appropriate hand hygiene during meal service for 1 (Resident #66) of 10 sampled residents observed for dining. Findings included: A facility policy titled, Handwashing/Hand Hygiene, revised 10/2023, revealed, 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. The policy indicated, 1. Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. after contact with blood, body fluids, or contaminated surfaces. A facility policy titled, Assisting the Resident with In-Room Meals, revised 12/2013, revealed, 11. Employees must wash their hands before serving food to residents. It is not necessary to wash hands between each resident tray; however, if there is contact with soiled dishes, clothing or the resident's personal effects, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-01 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 reasonable accommodation of resident needs was provided for one of three sampled residents (Resident 1) when Resident 1 was scheduled to be out of the facility (4/18/24) for an appointment for four hours during lunchtime and was not provided with food (packed food). This failure resulted in Resident 1 not having eaten any food from 10 a.m. until after 5 p.m. which placed Resident 1 at risk for hypoglycemia (low blood sugar). Findings: During record review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history), the AR indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included . TYPE 2 DIABETES MELLITUS (a disease that results in high blood sugar) . ACUTE KIDNEY FAILURE (a sudden condition where the kidneys cannot filter waste from the blood) . NEPHRITIC SYNDROME WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS (a condition that results 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 · F2020-02-20 · tag F0922 — failed to maintain the building's systems — widespreadHave enough backup water supply for essential areas of the nursing home.
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 staff were trained to access emergency water supplies. This failure placed residents, staff and visitors at risk of being without water in the event of an emergency. Findings: During an interview on 2/19/20, at 7:41 a.m., with the Administrator (ADM), the ADM stated, he did not know where the emergency water was stored. The ADM stated, I believe it [the emergency water] is in 50 gallon (gal) barrels, and a pump to access the water is outside. The ADM stated he did not know if staff knew how to access the emergency water, or access and assemble the pump, or attach the pump for the emergency water barrels. The ADM stated he did not know if there was a food grade water hose and/or buckets or other receptacle available to carry water in case of an emergency. The ADM stated he was not sure what was written in emergency water policy. During a concurrent interview and record review on 2/19/2020, at 9:22 a.m., with the ADM, the ADM presented an undated document titled, Emergency Water Pump Procedure (EWPP).…
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 · E2020-02-20 · 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 interview and record review, the facility failed to develop and implement a resident centered comprehensive care plan for three of five sampled residents (Resident 49, 70 and 97) when: 1. Resident 49's care plan intervention for the indwelling catheter tubing (tube inserted into the bladder to drain urine) was not implemented and the indwelling catheter tubing was not positioned in a manner that would allow urine to drain into the urine collection bag. This failure had the potential to allow for backflow of urine and increase the risk for a urinary tract infection (infection in the bladder). 2. Residents 70 and 97 were administered blood thinning medications and did not have a care plan developed with interventions that would monitor side effects from the use of blood thinning medications. This deficient practice had the potential to place Resident 70 and 97 at risk for complications of unmonitored blood thinning medications such as excessive bleeding or bruising. Findings: 1. During a concurrent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2020-02-20 · 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
Based on observation, interview, and record review, the facility failed to provide services which meet professional standards of quality for five of six sampled residents (Resident 24, 37, 46, 299 and 300) when: 1. Two of four sampled Licensed Vocational Nurse (LVN) 6 and LVN 2 failed to follow the facility's Policy and Procedure when obtaining a fingerstick blood sample (a procedure in which a finger is pricked with a lancet [a small needle device] to obtain a small quantity of blood for blood sugar testing) for Residents 37, 46, 299, and 300. LVN 6 and LVN 2 used the first drop of blood instead of using a clean blood sample from Resident 37, 46, 299, and 300's fingertips for fingerstick blood sugar level. This practice had the potential for residents on fingerstick blood sugar to have an inaccurate blood sugar level result. 2. Two of four sampled LVNs, LVN 6 and LVN 2 failed to follow the manufacturer's instructions for use when administering insulin lispro (medication for the treatment of diabetes - a disease with high blood sugar levels) with the Flex Pen (a dial-a-dose device,…
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 · E2020-02-20 · tag F0698 — failed to provide proper dialysis care — patternProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide dialysis services consistent with professional standards of practice for three of three sampled residents (Resident 33, 46 and 349) when the Dialysis (the process of artificial filtering and removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions) coordination of service Assessment Communication Record (DACR - form used to communicate pertinent dialysis resident assessment information from facility nursing staff to dialysis center staff ) form was not fully completed before or after dialysis treatment. The DACR form documents critical information regarding pre and post assessment for each resident before and after dialysis treatment, such as weight, blood pressure and access site condition to ensure resident are in stable condition prior to and after dialysis treatment. This failure resulted in the increased risk to residents experiencing dialysis undetected adverse reactions and not communicate the coordination of resident clinical status…
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 · E2020-02-20 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure 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 observation, interview and record review, the facility failed to ensure Licensed Nurses (LNs) possessed specific competencies required to accurately perform fingerstick blood sugar testing (a procedure in which a finger is pricked with a lancet [a device with an attached small needle used to prick the skin] to obtain a small quantity of blood for blood sugar testing) and for accurate use of insulin lispro Flex Pens (a dial-a-dose device, pre-filled insulin pen for discreet insulin medication administration) for five of six sampled resident's (Resident 24, 37, 46, 299 and 300) when: 1. Two of four sampled Licensed Vocational Nurse (LVN) LVN 6 and LVN 2 did not possess competencies to perform fingerstick blood sugar testing for Resident 37, 46, 299, and 300. LVN 6 and LVN 2 used the first drop of blood from Resident 37, 46, 299, and 300's fingertips for fingerstick blood sugar test. This practice had the potential for residents on fingerstick blood sugar to have inaccurate blood sugar test result. 2. Two of four sampled LVNs, LVN 6 and LVN 2 did not possess competencies for…
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 before2020-02-20 · 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 establish and maintain an effective infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable (contagious) diseases and infections when: 1. Certified Nursing Assistant (CNA) 3 did not perform hand hygiene (hand washing or use of hand sanitizer) while providing feeding assistance for two of 16 sampled residents (Resident 59 and 64) after touching unclean equipment, surfaces and residents during meal service. 2. Licensed Vocational Nurse (LVN) 5 did not wear Personal Protective Equipment (PPE - gloves, gown, and mask) prior to entering a contact isolation (precautions used to prevent the spread of infection) room for one of one sampled resident (Resident 70). These failures placed all residents, staff and visitors in the facility at risk of contracting communicable diseases and infections. Findings: During a lunch meal observation on 2/18/2020, at 12:30 p.m., in the memory care dining room, Certified Nursing…
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 before2020-02-20 · 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
Based on observation, interview, and record review, the facility failed to provide two of 16 sampled residents (Resident 64 and Resident 80) with a dignified dining experience in accordance with the facility policy and procedure when Certified Nursing Assistant (CNA) 3 assisted residents with their meals in a standing position. This deficient practice violated Resident 64 and 80's right to a dignified dining experience and had the potential to negatively affect their quality of life. Findings: During a lunch meal observation, on 2/18/20, at 12:30 p.m., in the dining room, Resident 64 sat at the dining room table while CNA 3 stood next to Resident 64 while assisting resident with her lunch meal. During a lunch meal observation, on 2/18/20, at 12:40 p.m., in the dining room, Resident 80 sat at the dining room table and was assisted by CNA 3 with his lunch meal. CNA 3 fed Resident 80 while standing next to him. During an interview on 2/18/20, at 12:45 p.m., with CNA 3, CNA 3 stated, she fed Resident 64 and Resident 80 while standing. CNA 3 stated she should have sat next to Resident 64…
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 before2020-02-20 · tag F0912 — isolatedProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide and maintain a minimum of at least 80 square feet per resident in multiple resident rooms (Rooms 101-108, 115-124, 130-137). This failure had the potential for residents to not have reasonable privacy or adequate living space. Findings: During a concurrent observation and interview on 2/18/2020, at 9:20 a.m., with Resident 97, in room [ROOM NUMBER], room [ROOM NUMBER] had three beds; bed A, B, and C. Bed A and bed B were approximately 1 foot apart. Resident 97 in bed A, stated his neighbor in bed B required assistance when getting out of bed. Resident 97 stated he didn't like his bed so close to bed B and that his bed was inches apart from bed B. Resident 97 stated bed B had been inches apart from his bed since he was placed into room [ROOM NUMBER] on 1/24/2020. During a concurrent observation and interview on 2/19/2020, at 3:25 p.m., with Certified Nursing Assistant (CNA) 4, two residents resided in room [ROOM NUMBER] with three beds. CNA 4…
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.
- No harm found · Bcited before2026-03-20 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review during the survey period of 3/17/26 through 3/20/26, the facility failed to provide the minimum of at least 80 square feet per resident in 27 of 37 multiple resident rooms (rooms 101, 102, 103, 104, 105, 106, 107, 108, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 128, 130, 131, 132, 133, 134, 135, 136, and 137).This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.Findings:During a concurrent observation and interview on 3/20/2026 at 9:16 a.m. with the Maintenance Director (MND), an environmental tour was conducted. The MND measured two rooms and stated the rooms did not meet the minimum square footage per resident as required by regulation. However, variations were in accordance with the particular needs of the residents. There was sufficient room observed for nursing care and resident ambulation. Wheelchairs and toilet facilities were accessible. The closets and storage space were adequate. Bedside stands were available. The waiver will not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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 CAMBRIDGE HEALTHCARE SERVICES — 32 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 | 2.5 | +2.5 vs chain |
| Health inspection | 4 of 5 | 2.4 | +1.6 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
The other 31 homes this chain runs (chain average 2.5★, 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 |
|---|---|---|---|---|
| CRESCENT FACILITIES OPERATIONS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/19/2006 |
| BERING PROPERTIES LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 6% | since 02/01/2007 |
| JENMAX ENTERPRISES LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 23% | since 02/01/2007 |
| JK-CSH JV LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 12% | since 11/01/2006 |
| MANHATTAN FIVE PARTNERS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 7% | since 11/01/2006 |
| WIN WIN ENTERPRISES, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 35% | since 02/01/2007 |
| BH ALLIANCE | Organization | INDIRECT OWNERSHIP INTEREST | — | since 11/01/2006 |
| THE JACOB WINTNER TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 11/01/2006 |
| THE WINTNER LIVING TRUST DATED 7/08/1992 | Organization | INDIRECT OWNERSHIP INTEREST | — | since 02/01/2007 |
| WINTNER, JACOB | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2007 |
| BRETSCH, GREGORY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/25/2019 |
| NIEL, MAXINE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/05/2024 |
| CAMBRIDGE HEALTHCARE SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2014 |
| BUTENKO, JULIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/24/2023 |
| CAPELA, HEIDI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/03/2023 |
| GUINAN, LONDON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/05/2024 |
| HASSELL, LANCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/25/2022 |
| LUTZ, LINDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2012 |
| SALAZAR, PAULINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/14/2020 |
| SMEDRA, IRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2007 |
| VERMA, ATUL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/04/2024 |
| 159 EAST ORANGEBURG LLC | Organization | ADP OF THE SNF | — | since 12/15/2006 |
CMS files one row per role, so the 39 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.
11 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.
About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 055849. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-20, 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.