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Montclair Manor Care Center

5119 Bandera St, Montclair, CA 91763 · For profit - Individual · 59 certified beds · (909) 626-1294 Medicare & Medicaid certified

Call the home — (909) 626-1294 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 27 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (27) — 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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
10144 Central Ave
Pharmacy
5507 Brooks St · (909) 447-7040 · Call to confirm hours
Grocery
Good Life<0.1 mi
10338 Central Ave · (909) 461-7479 · Call to confirm hours
Park
Saratoga Park, 5397 Kingsley St · (909) 626-8571 · Typically dawn to dusk
Place of worship
Revive0.3 mi
5080 Kingsley St

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

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 fell from 5 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.0%10.2%15.4%better
Long-stay residents who lose too much weight2.2%4.0%5.4%better
Long-stay residents with a catheter left in their bladder1.3%0.8%0.9%worse
Long-stay residents with a urinary tract infection2.2%1.2%2.0%worse
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened6.2%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.7%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers2.8%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control2.2%10.2%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table4.0%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine98.4%93.2%79.4%better
Long-stay hospitalizations per 1,000 resident days4.202.251.67worse
Long-stay outpatient ER visits per 1,000 resident days1.341.571.80better

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

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.

10.9%U.S. median 10.7%
Went back to hospital
59.1%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 59.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 22 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 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.

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

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 7.1–16.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge59.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge54.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting90.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.0%CMS range 3.9–13.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.761.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.49
RN hours/ resident / day
1.07
LPN hours/ resident / day
2.64
Aide hours/ resident / day
4.20
Total nurse hours/ resident / day
0.37
RN hoursweekends
35.0%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 59 beds and averages 45.1 residents a day — about 76% occupied, or roughly 14 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.20 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.64 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 3.98 hrs/resident/day on weekends vs 4.29 on weekdays — 7% thinner on weekends. RN hours go from 0.53 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below the national median of 45%.

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

Inspection trend

12
deficiencies at the latest standard inspection (2025-04-04)
4
at the previous standard inspection (2024-04-18)

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.

ABCDEFGHIJKL

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

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · D2025-04-30 · tag F0573 — isolated
    Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to provide medical records to the party responsible for one of four residents (Resident 1) in a timely manner, in accordance with the facility policy. This failure had the potential to compromise Resident 1 ' s rights which had the potential for Resident 1 ' s responsible party to experience psychosocial harm (mental harm and suffering). Findings During a concurrent interview and record review, on April 15, 2025, at 2:30 PM, with the Medical Records Director (Director), the facility ' s AUTHORIZATION FOR THE RELEASE OF CLINICAL INFORMATION, the authorization indicated, on March 19, 2025, the responsible party requested medical records. This information is verified and confirmed by the director. Director stated the party responsible was provided with the current records after 3 (three) days upon request; however, not all requested records were given. During a concurrent interview and record review on April 30, 2025, at 1:31 PM, the Director stated records should be provided within 72 hours upon request. During review of the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-04-04 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices in the kitchen when: 1. The ice machine had yellow grime (dirt clinging to or rubbed into a surface) in the ice chute (a passage, often filled with ice). This had the potential for contribution of microorganism (tiny living things like bacteria, fungi and algae that are too small to be seen with the naked eye) growth. 2. The floor under the reach-in refrigerator had a black grime and trash. This had the potential of pathogenic (something that can make you sick like germs or viruses) microorganisms to accumulate and attract pests. 3. Inside the refrigerator, the chicken was thawing (to unfreeze) over another set of meat. This had the potential of cross-contamination (contamination between two things). These failures had the potential to cause food-borne illness (a condition that occurs when a person consumes food or beverages contaminated with harmful microorganisms, toxins, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-04 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 pest (insect or animal such as rodents that can spread disease) control program when in the kitchen, a closet, used to store paper goods (paper cups, paper plates, napkins, etc.), had missing drywall. The hole caused by the missing drywall was covered by a metal mesh wire (a net like material that has holes) cover. This failure had the potential of making an entry for pests and causing food contamination for 54 medically compromised residents who receive food from the kitchen. Findings: During an observation on April 1, 2025, at 8:03 AM, in the kitchen's storage area, a closet, used to store paper goods, had a hole in the wall. Upon further inspection, it was noted that the hole was from a missing drywall. The hole was covered with a metal wire mesh. The openings between the metal mesh wire were about ½ inch wide. During an interview on April 3, 2025, at 10:38 AM, with the Registered Dietician (RD), the RD stated the expectation was for all walls to be intact. The RD acknowledged it 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-04 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    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 physician ordered therapeutic diets (special meal plans, made for people with health problems) were provided to three of 11 residents (Residents 34, 48, and 41) reviewed for dining observation when: 1. Residents 34 and 48 did not receive their physician ordered cardiac diet (low sodium, low fat diet). 2. Resident 41 did not receive the prescribed therapeutic diet for lunch on April 1, 2025. These failures had the potential to cause nutritional decline and unmet care needs for Residents 41, 34 and 48. Finding: 1. During a review of a facility document titled Order Listing Report [contains the resident's diet], it indicated Residents 34 and 48 had therapetic diets of .Regular Cardiac (Low fat, Low sodium), CCHO (Consistent Carbohydrate) NAS (No added Salt) with meals. During an interview on April 2, 2025, at 8:40 AM, with the Dietary Services Supervisor (DSS), the DSS stated they do not provide the cardiac diet at the facility. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-04 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 follow their daily approved menu for lunch on April 1, 2025, and April 2, 2025, when: 1. On April 1, 2025, Dietary [NAME] 1 (Cook 1), served puree (food that has been blended, pressed or ground to have a creamy texture) lasagna with #8 scoop (1/2 cup). The menu indicated the portion should be 1 cup. 2. On April 1, 2025, [NAME] 1, for the large portion orders served 1 ½ of lasagna. The menu indicated that it should be 1 ½ garlic bread not lasagna. 3. On April 2, 2025, Dietary [NAME] 2 (Cook 2), for the mechanical soft (foods that are easily swallowed) orders served #16 scoop (¼ cup). The menu indicated the portion should be #10 scoop (3/8 cup). These failures had the potential to compromise resident's nutritional status, when menus were not followed for 18 of 55 medically compromised residents (on puree, on large portion, or mechanical soft diets) who received food from the kitchen. Findings: 1. During a review of a facility document titled Orders Listing Report [contains the resident's diet], it indicated 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-04 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 resident's electronic health records (EHR- medical records kept on a computer system) were kept private and protected from public view for one of nineteen sampled residents (Resident 22) when the Assistant Director of Nursing (ADON) left Resident 22's EHR unattended, visible and viewable to the hallway at the nursing station. This failure had the potential to place Resident 22 at risk for her medical records to be viewed by other residents or healthcare providers who should not have access to Resident 22's medical records. Findings: During an observation on April 3, 2025, at 8:46 AM, there was no nurse at the nursing station. There was one computer facing the hallway, with the EHR open and viewable to the public. The computer screen showed Resident 22's weights. Upon further inspection, the person who accessed Resident 22's EHR was the Assistant Director of Nursing (ADON). During a concurrent observation and interview, on April 3, 2025, at 8:53 AM, in the nursing station, with the ADON, the ADON logged…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was updated in accordance with the facility's policy and procedure for one of four residents (Resident 41) reviewed for nutrition. This failure had the potential for Resident 41 to be at risk for continued nutritional decline, delayed interventions and unmet care needs related to weight loss and associated medical conditions. Findings: During a review of Resident 41's admission Record (contains demographic and medical information), it indicated Resident 41 was admitted to the facility on [DATE], with diagnoses of type 2 diabetes (a condition where the body has trouble using sugar properly, causing high blood sugar levels), and hypertension (elevated blood pressure). During a review of Resident 41's Weight Changes Note, dated February 21, 2025, at 3:29 PM, it indicated, Resident noted to have 16 lbs. (pounds) / 13.3% weight loss x 3…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 their catheter (tube that is inserted into your bladder, allowing your urine to drain freely) care policy and procedure was implemented for one of two residents (Resident 11) reviewed for catheter. This failure had the potential to place Resident 11 at risk for developing urinary infection (when bacteria enters and infects the urinary tract). Findings: During a review of Resident 11's face sheet (contains demographic and medical information), it indicated Resident 11 was admitted to the facility on [DATE], with diagnoses of hydroureter (a muscular tube that transports urine from the kidneys to the bladder, gets bigger than normal due to a backup of urine) caused by any blockage that prevents urine from draining into the bladder, chronic kidney disease (a long-term condition where the kidneys do not work as well as they should) and obstructive, and reflux uropathy (flow of urine is blocked). During a review of Resident 11's physician's order,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-04 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to coordinate and arrange the dialysis (procedure to remove waste products and excess fluid from the blood) appointment for one of one resident (Resident 36) reviewed for dialysis. This failure had the potential to place Resident 36 at risk of complications due to fluid overload (body has too much water). Findings: During a review of Resident 36's face sheet (contains demographic and medical information), it indicated Resident 36 was admitted on [DATE], with diagnoses of end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis) and diabetes (blood sugar is too high). During a review of Resident 36's physician's order, dated March 15, 2025, it indicated Will have an extra dialysis on March 17, 2025, per dialysis center due to fluid overload. During a concurrent observation and interview, with Resident 36, on April 4, 2025, at 9:07 AM, in Resident 36's room, Resident 36 was sitting on her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-04 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food preferences were accommodated for one of four residents (Resident 11) reviewed for nutrition when Resident 11 was served green beans for lunch on April 1, 2025. This failure had the potential to result in unmet care of needs for Resident 11 which could potentially affect the resident's nutrition status. Findings: During a review of Resident 11's admission Record, (contains demographic and medical information), it indicated Resident 11 was admitted to the facility on [DATE], with diagnoses of chronic systolic heart failure (a long-term condition where the heart struggles to pump blood effectively), depression (a persistent mood disorder characterized by a sustained feeling of sadness and loss of interest), and muscle wasting (the loss of muscle mass and strength). During an interview, with Resident 11, in Resident 11's room, on April 1, 2025, at 12:03 PM, Resident 11 stated she often gets served food that does not accommodate…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Dcited before2025-04-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when: 1. A Certified Nursing Assistant (CNA 1) did not wear a protective gown while providing care for Resident 31, who was on enhanced barrier precautions (EBP- infection control intervention designed to reduce the transmission of harmful germs by wearing gown and gloves during high-contact care activities). 2. Resident 18's oxygen tubing (tube that contains two open prongs intended to deliver oxygen into the nose) was not changed in accordance with the facility's policy. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 54 highly vulnerable residents whose health conditions were already compromised. Findings: 1. During a review of Resident 31's admission Record (contains demographic and medical information), it indicated Resident 31 was admitted to the facility with the diagnoses 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-04 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure two sinks in the kitchen were in safe operating condition when: 1. The hand washing sink drainpipe (a pipe carrying off dirty water) was not connected and turbid water was leaking on the kitchen floor. 2.The dish washing waterline (a hose that carries water into the sink) under the sink was leaking water onto the kitchen floor. These failures had the potential of causing water damage, mold (a type of fungus that grows in damp, warm places and can look like fuzzy spots or patches) growth, causing staff injury, and contamination compromising the health of the 54 vulnerable residents. Findings: 1. During an observation on April 1, 2025, at 8:00 AM, in the kitchen, with the Dietary Aid, there was a pool of water on the floor next the handwashing sink. The drainpipe of the handwashing sink was not connected, and turbid water was leaking onto the floor. During an interview on April 3, 2025, at 10:32 AM, with the Registered Dietician (RD), the RD stated the sink should not be leaking. The RD further stated…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-18 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record reviews, and facility document and policy review, the facility failed to have evidence that pharmacy recommendations were communicated to the physician, and physician response was documented for 1 (Resident #11) of 5 sampled residents reviewed for unnecessary medications. Findings included: A review of a facility policy titled Pharmacy Services Overview, revised in April 2019, revealed, 4. The Consultant Pharmacist will provide specific activities related to medication regimen review including: a. a [sic] documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines. b. providing [sic] the facility with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review and to be completed within 14 days. A review of Resident #11's admission Record indicated the facility admitted the resident on 12/28/2023 with a diagnosis of stage 3 chronic kidney disease. A review of Resident #11's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-18 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, the facility failed to ensure single-use packets of topical medications were not stored at the bedside for 1 (Resident #14) of 1 sampled resident observed with medications stored in their room. Findings included: A review of an admission Record revealed the facility admitted Resident #14 on 09/29/2023 and most recently readmitted the resident on 12/05/2023. A review of a quarterly Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 03/08/2024, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. An observation on 04/16/2024 at 9:48 AM, with Licensed Vocational Nurse (LVN) #3 present, revealed two individual-use packets of topical medications were stored at Resident #14's bedside. One packets was A&D ointment (a skin protectant), and the other packet was hydrocortisone cream (a topical corticosteroid cream). LVN #3 said the medications were not allowed to be kept at the resident's bedside. A review of Resident #14's Order Summary…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-18 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility policy review, the facility failed to ensure documentation was completed and dated accurately for 1 (Resident #12) of 5 sampled residents reviewed for advance directives. Findings included: A review of a facility policy titled Physician Orders for Life Sustaining Treatment (POLST) or Request Regarding Resuscitative Measures Form, with a revision date of [DATE], revealed, 1. Request Regarding Resuscitative Measures: is a written document, signed by an individual with capacity, or a legally recognized health care decision maker, and that [sic] individual's physician, that directs a health care provider regarding resuscitative measures. The policy revealed that this included B. A Physician Orders for Life Sustaining Treatment (POLST) form, as approved by the Emergency Medical Services Authority. Further review revealed, b. A substantially similar printed document is valid and enforceable if all of the following conditions are met: The form is signed by the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-10-07 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when two sinks in the kitchen did not have an air gap (separation of the drainpipe on a sink to prevent backflow of contaminated water during negative pressure). This failure had the potential to expose 48 highly vulnerable residents who received food from the kitchen to food-borne illness (food poisoning). Findings: During a concurrent observation and interview, with the Dietary Services Supervisor (DSS), in the kitchen, on October 4, 2022, at 8:15 AM, two sinks, one food preparation sink and one dishwashing sink, did not have an air gap. The DSS confirmed the sink drainpipes did not have air gaps. During a concurrent interview and record review, with the DSS and the Maintenance Supervisor (MS), on October 6, 2022, at 2:28 PM, the DSS and the MS reviewed a document titled ACCIDENT PREVENTION- SAFETY PRECAUTIONS, dated December 2014, which indicated .Food preparation sinks . and other equipment that discharge liquid waste or condensate shall be drained…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-10-07 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose 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 one of three outside dumpster lids were completely closed. This failure had the potential to attract vermin (pest or animals that spread diseases) in a facility that cares for 49 medically compromised residents. Findings: During a concurrent observation and interview, on October 4, 2022, at 11:12 AM, with the Maintenance Supervisor (MS), the outside garbage storage area was inspected. There were three outside dumpsters. One of the outside dumpster's lid was not closed completely. It was observed to be propped open with a long metal bar. There were plastic forks, straws, sugar packets, creamer, and milk containers on the ground. The MS stated the garbage dumpster should not be propped open and the outdoor garbage storage area should be clean and free of trash. A review of the facility's policy and procedure (P&P) titled, Food Related Garbage and Rubbish Disposal, dated December 2014, indicated, .7. Outside dumpsters provided by garbage pick up services will be kept close and free of surrounding litter.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-10-07 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 8's clinical record, the admission Record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included, type 2 diabetes mellitus, end stage renal disease (condition in which kidneys are not working), and hyperlipidemia (excessive fat in the blood). During an observation on October 6, 2022, at 7:20 AM, Resident 8 was sitting in her wheelchair, eating breakfast. Resident 8 stated she was leaving for her dialysis treatment (procedure to remove waste products and excess fluid from the blood). A concurrent interview and record review with the Director of Nursing (DON) was conducted on October 6, 2022, at 3:12 PM. The DON reviewed Resident 8's September 2022 Medication Administration Record (MAR), which indicated the following missing documentations: a. Amlodipine Besylate (medicine to treat high blood pressure) Tablet 5 MG by mouth one time a day, to be given at 9:00 AM, for hypertensive kidney disease, was left blank on September 15 and September 29. b.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-10-07 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 control practices when: 1. Staff did not perform proper hand hygiene during medication pass for three residents (Residents 2, 248, 6, and 8). 2. Staff did not follow facility policy and procedure for wound care for Resident 21. 3. Resident 35's foley catheter bag (a bag connected to the catheter to collect urine) was not changed in accordance with facility policy and procedure. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasites) to other residents and staff in the facility. Findings: 1.a. During a review of Resident 2's admission Record (clinical record with demographic information), the admission Record indicated, Resident 2 was admitted on [DATE], with the diagnoses of fracture of lower end of left femur (broken bone in the thigh), hypertension (high blood pressure), and myocardial infarction (heart not getting enough oxygen). A medication…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-07 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 accurately code the Minimum Data Set Assessment (MDS - a computerized assessment instrument) for one resident (Resident 31) reviewed for communication. This failure had the potential to cause inaccuracy in identifying Resident 31's care and support needs, and cause delay in these needs being met. Findings: During an observation on October 4, 2022, at 12:56 PM, Resident 31 was in bed, using simple and small words in English, combined with hand gestures, in an attempt to communicate with staff who came into the room. No communication aides were seen at bedside. During an interview with Certified Nursing Assistant 1 (CNA 1) on October 4, 2022, at 1:01 PM, CNA 1 stated that Resident 31 was primarily Mandarin speaking, and she attempts to communicate with staff by using a few simple words in English, accompanied with hand gestures. During a concurrent interview and record review with the MDS Coordinator on October 6, 2022, at 1:44 PM, the Resident's Quarterly MDS assessment, dated August 12, 2022, was reviewed.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review, the facility failed to develop a comprehensive and personalized care plan to address the needs and goals for two of 24 sampled residents (Residents 31 and 150) when: 1. Resident 31 did not have a personalized care plan for communication. 2. Resident 150 did not have a care plan for diagnosis of cataracts (a condition which causes blurry vision). These failures had the potential to prevent the resident's medical and psychosocial needs from being met. Findings: 1. During a record review of Resident 31's medical record, the admission Record (contains demographic and medical information), indicated Resident 31 was admitted to the facility on [DATE], with diagnoses which included dysphagia (unable to, or having difficulty swallowing), hypertension (high blood pressure levels), and cerebral infarction (lack of blood supply to the brain). During an observation on October 4, 2022, at 12:56 PM, Resident 31 was in bed, using simple and small words in English, combined with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-07 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 appropriate treatment and services to increase range of motion (measurement of how far you can move a specific joint or other body part) or to prevent further decrease in range of motion for one of three sampled residents (Resident 38), when the Restorative Nursing Assistance (RNA) active range of motion (A/AROM) program was not being provided to Resident 38, as per physician orders. This failure had the potential to decrease Resident 38's range of motion and could have resulted in worsening of contractures and mobility. Findings: During a concurrent observation and interview, on October 4, 2022, at 9:00 AM, Resident 38 was observed to be in bed, unable to move her right arm. Resident 38 stated she was not getting any exercises done. A review of Resident 38's clinical record titled admission Record, (a document containing clinical and demographic data) indicated an admission date of November 15, 2008, with the diagnoses of hemiplegia (unable to move one side of the body) affecting the right side,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-07 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube - a tube inserted through abdomen that delivers nutrition and hydration directly to the stomach) was implemented for one resident (Resident 39) reviewed for G-tube. This failure had the potential to increase the risk for aspiration (when food or liquids enter the lungs) and compromise Resident 39's health. Findings: During a review of Resident 39's clinical record, the admission Record (contains demographic and medical information), indicated Resident 39 was admitted to the facility on [DATE], with diagnoses which included, hemiparesis following a cerebrovascular disease affecting left dominant side (paralysis on left side of body due to a stroke), dysphagia (difficulty swallowing), and gastrostomy status (a surgical operation for making an opening in the stomach). During a review of Resident 39's Order Summary Report, it indicated an order, dated June 13, 2022,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-07 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to properly record and account for a medication removed from one of 12 Emergency Kits (E-kit- secure box kept with medications inside for urgent use). This failure had the potential to cause medications to not be readily available for resident during an urgent situation in a highly vulnerable population of 49 residents. Findings: A medication storage inspection was conducted with a Registered Nurse(RN 1) on October 6, 2022, at 7:50 AM. One non-antibiotic (medications that are not in the antibiotic category) oral emergency kit was observed to have been opened for use and re-sealed with black ties. RN 1 re-opened the emergency kit and three blank record sheets were seen inside. There was no record of what medication had been used. RN 1 stated when a medication is used, it should be documented on the record sheet inside of the kit. RN 1 confirmed one tablet of Coumadin (type of blood thinner medication) 5 milligram (mg - unit of measurement) had been removed from the emergency kit. During an interview with the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-04-04 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure ten rooms (Rooms 4, 5, 7, 8, 10, 11, 12, 14, 16 and 18) measured at least 80 square feet per resident. This failure had the potential for the residents housed in Rooms 4, 5, 7, 8, 10, 11, 12, 14, 16, and 18 to not have the ability to move about freely if the square footage limited their personal space. Findings: During a concurrent interview and record review, with the Administrator (Admin), on April 2, 2025, at 2:30 PM, the Admin reviewed the Entrance Conference Checklist and stated the facility had room waivers for Rooms 4, 5, 7, 8, 10, 11, 12, 14, 16, and 18 for less than 80 square feet. During an environmental tour with the Maintenance Supervisor (MS) and the Admin, on April 3, 2025, at 3:35 PM, Rooms 4, 5, 7, 8, 10, 11, 12, 14, 16, and 18 were inspected and the residents' rooms and their measurements of livable space were noted as follows: 1. room [ROOM NUMBER] (three beds) measured: 237.3 sq. ft. [square feet] (79.1 sq. ft.…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2024-04-18 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and facility document review, the facility failed to ensure the required 80 square feet (sq ft) per resident was met for 12 of 18 resident rooms (rooms 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16 and 18). Findings included: A review of a facility letter dated 07/12/2023 revealed the facility requested a room size waiver for nine rooms in the facility. A review of a facility document titled Client Accommodations Analysis dated 04/17/2024 revealed that rooms 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, and 18 did not provide each resident that resided in the rooms with 80 sq ft per resident. During an interview on 04/18/2024 at 1:14 PM, the Director of Nursing (DON) stated that she knew the facility had a waiver for room sizes. She stated that the size of the rooms did not affect the care that was provided and that she had not received any complaints about the size of the rooms. During an interview on 04/18/2024 at 1:40 AM, the Assistant Administrator (AA) stated that the size of the rooms did not affect resident care. She stated that she had no complaints from…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2022-10-07 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for nine of 19 resident rooms. This failure had the potential to affect the resident's health and safety and prevent the residents from maintaining their highest level of well-being by limiting the movements of these residents in their rooms. Findings: During an interview with the Administrator (Admin), on October 4, 2022, at 8:26 AM, the Admin stated the facility had nine of 19 resident rooms (Rooms 4, 5, 7, 8, 10, 11, 12, 14 and 16) which had less than the required square footage (80 sq. ft. of livable space). During an environmental tour with the Maintenance Supervisor (MS), on October 5, 2022, at 10:33 AM, nine of the 19 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows: i. room [ROOM NUMBER] (3 beds) measured: 232.83 sq. ft. (77.6 sq.…

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

    Environmental Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to EVA CARE GROUP — 9 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 →

RatingThis homeChain avg
Overall 5 of 53.4+1.6 vs chain
Health inspection 4 of 52.6+1.4 vs chain
Staffing 4 of 54.4-0.4 vs chain
Quality measures 5 of 54.0+1.0 vs chain
The other 8 homes this chain runs (chain average 3.4★, 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 / managerTypeRoleShareSince
CHEN, JENQIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 04/30/2001
CHEN, TZE-YUNIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 04/30/2001
PADAMA, JOHNIndividualMANAGING CONTROL - GOVERNING BODYsince 10/02/2017
NARCISSE, ROSEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/23/2024
TSAI, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/28/2012

CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$6.7M
Net patient revenuemost recent cost report
+0.4%
Operating marginrevenue minus expenses
$240K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 13%Other / private 10%

About 77% 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 $240K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$374per resident / day
operating cost
$11,372per month
≈ monthly operating cost
$375per day
avg. revenue, all payers

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

What families pay in CA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055718. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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