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Moraga Post Acute

348 Rheem Boulevard, Moraga, CA 94556 · For profit - Limited Liability company · 49 certified beds · (925) 376-5995 Medicare & Medicaid certified

Call the home — (925) 376-5995 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Mar 20261 actual-harm citation1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

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)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — 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 (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)

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) 2 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
1100 Moraga Way · (925) 794-6014 · Call to confirm hours
Pharmacy
346 Rheem Blvd · (925) 247-5602 · Call to confirm hours
Grocery
Safeway1.7 mi
1355 Moraga Way · (925) 376-9492 · Call to confirm hours
Park
2100 Donald Dr · (925) 888-7045 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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 increased5.3%10.2%15.4%better
Long-stay residents who lose too much weight0.0%4.0%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms18.1%7.3%6.5%worse
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 injury1.0%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened0.0%9.8%16.1%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication9.6%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers1.0%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control1.2%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 table1.6%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.3%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine98.7%93.2%79.4%better
Short-stay residents rehospitalized after admission19.3%23.0%22.6%better
Short-stay residents with an outpatient ER visit5.4%11.2%12.0%better

* 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.

63.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 237 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.1%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
79.4%U.S. median 56.6%
Met the expected recovery
0.68U.S. median 0.31
Therapy hours / resident / day
0.39hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 79.4% 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 97 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 0.68 therapist hours per resident per day in 2026Q1 — more than 91% 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 SNF63.1%CMS range 56.0–68.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 8.2–14.110.7%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 discharge79.4%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 discharge73.2%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 discharge76.3%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 setting98.1%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 discharge83.6%98.7%Oct 2024–Sep 2025CMS 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 stay0.8%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 hospitalization7.7%CMS range 4.8–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.091.02Oct 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

0.36
RN hours/ resident / day
1.44
LPN hours/ resident / day
2.31
Aide hours/ resident / day
4.10
Total nurse hours/ resident / day
0.30
RN hoursweekends
39.3%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 49 beds and averages 46.5 residents a day — about 95% occupied, or roughly 2 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.10 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 is below 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 4.25 on weekdays — 12% thinner on weekends. RN hours go from 0.38 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

1
deficiencies at the latest standard inspection (2024-11-08)
9
at the previous standard inspection (2023-11-03)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · G2026-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for one of three sampled residents (Resident 1) to prevent falls and sustained injuries when Resident 1, with history of unwitnessed falls, lost her balance while walking from her bed to room's doorway and fell forward to the ground. This failure resulted in Resident 1 sustaining a laceration to the left frontal part of the head with uncontrolled bleeding, transferred to Acute Care Hospital for follow up care and diagnosed with subarachnoid hemorrhage (a life-threatening condition caused by bleeding into the space surrounding the brain).During a review of Resident 1's admission Record (AR), printed on 2/23/26, AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included abnormalities of gait (a person's manner of walking) and mobility, age related physical debility, osteoarthritis, wedge compression fracture of first lumber vertebra (fractured back) and vascular…

    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 · Dcited before2026-04-13 · 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 ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for residents (1-9), the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered). 2. The facility failed to ensure, between 4/1/22-7/31/22, the Consultant Pharmacist identified the scheduled (controlled medication, narcotic) medication system…

    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 before2026-04-13 · tag F0836 — isolated
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted 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 the social services department was directed and supervised by a qualified social worker according to State regulation for more than 9 years.This failure resulted in all residents receiving social services care from unqualified staff.During an interview on 3/24/26 at 9:45 a.m. with the Social Services Director (SSD), the SSD stated they were the only staff member in the facility's social services department and had worked there for more than 9 years as the social services director. The SSD stated they did not have a bachelor's degree in any field and that their training for the position consisted of a certificate course they completed in 1997. The SSD further stated they had not received any continuing education or additional training since obtaining the certificate in 1997.During a concurrent interview and record review on 3/24/26 at 10:00 a.m. with the Operations Manager (OM), two job descriptions for the SSD, dated 7/2022 and 12/2025, were reviewed. Both job descriptions were signed by the SSD. 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-12 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary drugs when:1. Interdisciplinary team (IDT-a group of professionals from different disciplines working together to provide the greatest benefit to the resident, which included the resident, the resident's family and/or representative, whenever possible, develops and implements approaches to care that are both clinically appropriate and person - centered.) did not address Resident 1's angry outbursts and hallucinations (perceptual experiences in the absence of real external sensory stimuli) and identify person-centered non-pharmacological/behavior approaches prior to administering Resident 1 Quetiapine Fumarate (Seroquel), an antipsychotic medication for vascular dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. There are many types and causes 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-12 · 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, record review, and comprehensive assessment, the facility failed to ensure one of three sampled residents (Resident 1), with occasional incontinence of bladder and bowel, received appropriate care services and assistance to maintain and restore continence to the extent possible. This failure had the potential to place Resident 1 at risk for infections, falls and injuries. During a review of Resident 1's admission Record (AR), printed on 5/6/26, AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included history of falling, muscle wasting and atrophy, age related osteoporosis, and dementia with mood disturbances (memory loss). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/3/26, the MDS indicated Resident 1 had occasional incontinence of bladder and bowel. MDS indicated trial toileting program (e.g., scheduled toileting,…

    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 · Dcited before2026-03-05 · tag F0836 — isolated
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and 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 observation, interview and record review, the facility failed to follow state regulation in ensuring residents were housed in approved areas when the facility allowed one of two sampled residents (Resident 2) to be housed in a conference room without a sink from admission to discharge totaling six weeks.This failure placed Resident 2 at risk for infection when the facility was unable to provide a sink for handwashing and could only provide a commode for toileting.A review of Resident 2's admission record indicated Resident 2 was admitted on [DATE] with a diagnosis of neutropenia (blood disorder which white blood cells count is reduced), hemiplegia (the loss of muscle function on one side of the body), hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body), functional diarrhea and heart failure. The record further indicated Resident 2 discharged on 2/11/26.During a record review of Resident 1's minimum data set (MDS, an assessment tool to guide…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-08 · 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, interview, and record review, the facility failed to ensure the safe labeling, open date, and expiration date of eye drop medication for 2 (Resident 98 and Resident 100) out of 2 residents. These failures had the potential to result in residents being given medication with decreased potency and efficacy. Findings: During an observation of Medication Cart A on 11/4/24, at 11:45 a.m., with Assistant Director of Nursing (ADON), Resident 98's Latanoprost (medication to treat high pressure in the eye caused by glaucoma) Ophthalmic solution label indicated an expiration date of June 2026, to refrigerate until opening and to discard 42 days after opening. No open date was indicated on the label. During an observation of Medication Cart B on 11/4/24, at 12:00 p.m., with ADON, Resident 100's Latanoprost Ophthalmic solution label indicated an expiration date of June 2026, to refrigerate until opening and to discard 42 days after opening. No open date was indicated on the label. During interview on 11/4/24, at 12:05 p.m., with ADON, ADON stated the eye drops should have…

    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 · Fcited before2023-11-03 · tag F0761 — failed to label and store drugs safely — widespread
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper storage of medication when the following was noted: 1. Two bottles of expired 20 milliliters (ml) of lorazepam (a medication used to treat anxiety) for Resident 10 were stored in a dedicated refrigerator for ready to use medications. 2. The lid of black colored Medication Disposal Bin was kept very loosely open in medication storage room. The failure to dispose of expired lorazepam medication, posed a potential risk of utilizing the medication with decreased effectiveness for anxiety to Resident 10. The failure to ensure proper security of the Medication Disposal bin posed a potential authorized/unauthorized access to medications in the bin. Findings: 1. During an observation on [DATE] at 09:57 a.m. in Medication room [ROOM NUMBER], with Licensed Vocational Nurse (LVN) 1, two bottles of 20 ml of lorazepam with expiration date of [DATE] for Resident 10 were kept in a dedicated refrigerator for ready to use medications. LVN 1…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-11-03 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to ensure when it did not hire a full-time registered dietitian, the person designated to serve as the director of food and nutrition services met the federal and state educational qualifications for a dietary manager position. The lack of full-time, qualified oversight of food and nutrition staff placed residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and/or decreased nutrient intake which had the potential to result in malnutrition and/or death. Findings: During an interview on 10/30/23 9:35 a.m., with Dietary Supervisor (DS), DS stated he worked fulltime as the Dietary Supervisor. DS stated he had worked at the facility for one year. During an interview on 10/31/23 at 12:23 p.m., with Registered Dietitian (RD), RD stated he worked at the facility part time. RD stated he was usually at the facility two days a week. During an interview on 11/01/23 at 9:18 a.m., with DS, DS stated he had completed an online training…

    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 · Fcited before2023-11-03 · 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, interviews and record review, the facility failed to ensure storage and preparation of food under sanitary conditions when: 1. The facility failed to ensure two of two facility ovens were maintained in safe operating condition to provide cooked meals according to mealtime schedules: oven 1 was unable to cook chicken to the required food safety temperature; oven 2 was inoperable. 2. The facility failed to maintain the physical environment: the countertop toaster oven had brownish black debris both on the oven knobs and inside the oven; the kitchen floors had cracked tiles with blackish discoloration; a ceiling vent was covered with blackish, dusty material; the grease trap area was malodorous and not securely covered; a storage cabinet drawer did not fully close. These failures had the potential to result in food borne illnesses for residents who received food from the facility's kitchen. Findings: 1. During an observation on 10/30/23 at 1:15 p.m., with Dietary Supervisor (DS), in the kitchen, oven 2 had plates stored inside the oven. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-03 · tag F0755 — failed to provide safe pharmacy services — pattern
    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 interview and record review, the facility failed to ensure the pharmacist provided consultation services to ensure there was a record system for receipt and disposition and reconciliation of all controlled drugs maintained for three years. The failure to maintain records had the potential to result in drug diversion. Findings: During and concurrent interview and record review on 11/1/2,3 at 11:06 a.m., with Director of Nursing (DON), the controlled medication disposition binder was reviewed. The DON stated she had a huge stack of unorganized logs and medications packages for controlled medications which had been sent for disposal on 10/5/23. DON stated she had organized the logs and placed them in the disposition binder; the binder showed the last previous transfer for destruction date was 10/5/22, with no transfer for final disposal of controlled medication between 10/5/2022 to 10/5/2023. The DON stated she and the facility's Pharmacist (Pharm) were responsible to dispose of the controlled medications into the final incinerator container together. The DON stated Pharm had…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · E2023-11-03 · 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

    Based on observation, interview, and record review, the facility failed to maintain complete and accurate Medical Records for three (Residents 9, 30, and 15) of eleven sampled residents, when: 1. Licensed Vocational Nurse (LVN) 2 failed to immediately document in Resident 9's medical record, the administration of Resident 9's oxycodone (a controlled medication: medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence). 2. LVN 2 and Licensed Vocational Nurse 5 (LVN 5) failed to document administration of multiple medications for Resident 30 on 10/6/23, 10/14/23, 10/18/23, 10/19/23. 3. Resident 15's care plan indicated Resident 15 was restricted to her room for infection control reasons since 12/17/20, while observations and interviews indicated Resident 15 had left her room for ambulation therapy outside her room, as well as locomoting in a wheelchair in the lobby and dining areas. The failure to maintain complete and accurate medical records 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-03 · 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

    Based on observation, interview, and record review, the facility failed to ensure proper infection prevention and control practices when Licensed Vocational Nurse (LVN) 3 did not perform hand hygiene during medication administration for Resident 2, Resident 5, and Resident 151. This failure to ensure proper hand hygiene had the potential risk for transmission of infection to Residents 2, 5, 151, and throughout the facility. Findings: During an observation on 10/31/23 at 08:58 a.m., Licensed Vocational Nurse (LVN) 3 prepared Resident 2's morning medications outside his room and put them on a medication tray. Without performing hand hygiene, she put on an isolation gown and a pair of gloves. LVN 3 stated Resident 2 was on Contact Isolation (infection control measures used for a resident with infectious disease that may be spread by touching). LVN 3 went inside Resident 2's bathroom, turned the faucet on, grabbed water for medication administration, poured water in each medicine cup with the same gloved hands. LVN 3 then closed Resident 2's room door by touching the doorknob, picked up…

    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 · D2023-11-03 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool used to guide care) functional status on mobility for one of two sampled residents (Resident 15). The MDS assessment inaccurately showed Resident 15 was not able to walk due to health and safety reasons. This failure resulted in an inaccurate reflection of Resident 15's medical condition and placed her at risk for receiving inappropriate care. Findings: During a review of Resident 15's admission Record, dated October 2023, the record indicated Resident 15 was readmitted to the facility in May 2019. During an interview on 11/02/23 at 5:14 p.m. with Restorative Nursing Assistant (RNA), RNA stated Resident 15 was able to walk with assistance in the hallways and outside on the patio. RNA stated he usually assisted Resident 15 for ambulation for at least three times per week. During a review of Resident 15's RNA Weekly Summary, dated 9/29/23 and 10/6/23 showed Resident 15 received RNA…

    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 · D2023-11-03 · tag F0644 — isolated
    Coordinate 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete and/or update the Level I Preadmission Screening and Resident Review (PASARR, a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care) assessment for one of one sampled resident (Resident 15) for a period of over four years. This failure resulted in an inaccurate reflection of Resident 15's medical status and had the potential to result in Resident 15 not receiving the care and services appropriate for her condition. Findings: During a review of Resident 15's admission Record, dated October 2023, the record indicated Resident 15 was originally admitted to the facility in December 2018. During a concurrent interview and record review on 11/3/23 at 11:58 a.m. with Director of Nursing (DON), Resident 15's PASARRs, dated 12/12/18 and 6/7/19 were reviewed. The DON stated the facility was expected to complete a PASARR screening prior to residents' admission to the facility. The DON…

    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 · D2023-11-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 assistance needed for fingernail care for one (Resident 30) of three sampled residents when Resident 30 had long fingernails with blackish material under the nail tips. This failure had the potential for Resident 30 to be injured by long fingernails and develop an infection. Findings: Review of the Minimum Data Set (MDS Resident Assessment tool used to guide care), dated 8/25/23, indicated Resident 30's diagnoses included stroke (brain injury when blood flow to a part of the brain stops) and diabetes mellitus (a long-term (chronic) disease in which the body cannot regulate the amount of sugar in the blood). Resident 30 had clear speech, was able to understand others and be understood. Resident 30 required extensive physical assistance from one-person for personal hygiene, including combing hair, brushing teeth, shaving, washing, and drying face and hands. Review of Resident 30's Activities of Daily Living (ADLs) care plan, dated 8/25/23, indicated Resident 30 required extensive assistance with ADLs 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide Resident 1's Representative (RR) with a summary of the baseline care plan. This failure resulted in the lack of information about Resident 1's care. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), moderate protein calorie malnutrition, dysphagia (difficulty swallowing) need for assistance with personal care, malignant neoplasm (abnormal growth, cancer) of connective and soft tissue, presence of a cardiac pacemaker (small device implanted in the chest to help control the heartbeat), and atrial fibrillation (irregular and very rapid heart rhythm). The record indicated RR as Resident 1's responsible party/representative. During a telephone interview with RR on 2/1/23 at 11:32 a.m., RR stated not having received a summary of Resident 1's care plan or even a telephone call…

    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 · D2023-08-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide treatment and care in accordance with professional standards of practice in caring for the resident with a Foley catheter (a flexible tube that is passed into the bladder to drain urine) when: - Resident 1's urine characteristics (amount, color, odor, transparency) was not assessed and monitored for any changes. - Resident 1's intake and output (the measurement of the fluids that enter the body [intake] and the fluids that leave the body [output]) were not monitored per the physician's order. This failure contributed to Resident 1's transfer to the acute hospital and required intravenous (IV) fluids (administration of fluids into the person's veins) for fluid resuscitation (replenishing bodily fluids lost through sweating and bleeding). Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with diagnoses that included hypertension (high blood pressure), moderate protein calorie malnutrition, dysphagia (difficulty…

    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 · Fcited before2021-07-09 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    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 document review, the facility failed to ensure the competency of the Dietary Services Supervisor (DSS) and the Registered Dietitian (RD) when: 1. DSS did not ensure: the kitchen was maintained in a safe and sanitary manner and maintenance needs were reported for the kitchen (Cross-reference F 812); food preparation methods conserved nutritive value of the food (Cross-reference F 803); food was palatable (Cross-reference F 804); resident food preferences were provided (Cross-reference F 806); and kitchen staff were trained on perspective duties (Cross-reference F 802); 2. DSS did not ensure there was a system for dating food with appropriate use-by-dates; 3. DSS did not ensure thermometers were calibrated; 4. The RD did not provide consultation to DSS to ensure the kitchen was maintained in a safe and sanitary manner (Cross-reference F 812) and foods were prepared in a manner to conserve nutritive value and flavor and were palatable (Cross-reference F 804). These…

    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 · Fcited before2021-07-09 · 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 document review the facility failed to store, prepare, and distribute food safely when: 1. Perishable food was not stored in a reach-in refrigerator at 41 degrees Fahrenheit (F) or below. 2. Dirty water from the dirty side of the dish machine area splashed into the adjacent 3-compartment sink area where clean pans were stored. 3. Dietary staff did not follow proper hand hygiene and glove use procedures when cleaning and handling dishes and handling ready to eat food. 4. Multiple areas and surfaces in the kitchen were dusty, had buildup of debris and grime including two food equipment storage cabinets, floors in the dry storage room, over 50 dead flies stuck on the wall by the toaster, and dust and dirt build up in the window tracks and sills that ran all along the length of the windows behind the tray line steam table. 5. Cooking and food service equipment was not maintained and stored in clean condition including a large frying pan, a half hotel pan, 5 large pans used 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2021-07-09 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, the facility failed to ensure the infection control program for was fully implemented for COVID-19 and revised their policy and procedure (P&P) to include when and whom to report possible communicable disease or infections when; 1. The facility did not report an outbreak of nausea, vomiting, and diarrhea to the California Department of Public Health (CDPH) of a gastroenteritis (sometimes called stomach flu) outbreak. 2. There was no screening of staff members for COVID-19 (a new coronavirus causing a respiratory illness and outbreak that is easily spread) symptoms from 7/3/21-7/5/21 prior to providing care to the residents. 3. The facility did not immediately test residents with nausea, vomiting, and diarrhea to rule out possible COVID-19. 4. There was no surveillance and verification of staffs' COVID-19 vaccination status. 5. The licensed nurse did not perform hand hygiene prior to and after administering medications between residents. 5. The licensed nurse did not don gloves while administering injections to Residents 35 and 37.…

    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 · E2021-07-09 · tag F0756 — failed to review each resident's drug regimen — pattern
    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 and record review, the facility failed to act upon the pharmacist's identified medication irregularity for one (Resident 41) of 12 sampled residents when; 1. Licensed nurses did not hold midodrine (for low blood pressure) as ordered by the physician. 2. Resident 41 continued to received fludrocortisone (corticosteroid) twice daily instead of once every day. These failures had the potential for Resident 41 to receive unnecessary drugs and suffer adverse medication side effects. Findings: Review of the admission Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 6/2/21, indicated Resident 41's diagnoses included Atrial fibrillation (irregular heart rhythm) and concussion edema (swelling) of cervical spinal cord encounter. Review of Resident 41's physician orders dated 5/27/21 indicated the physician ordered midodrine 5 milligram (mg) tablet by mouth, two times a day for hypotension (low blood pressure), hold for systolic (top number) blood pressure (SBP) greater than 135. Review of the Medication Administration Record (MAR) dated 5/1/21 through…

    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 · D2021-07-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to ensure one of 12 sampled residents (Resident 7) was aware of the benefits and limitations of having a knee high plastic zipped barrier at the entrance to her room. This failure resulted in Resident 7 to be unaware of the rationale for having a plastic zipped barrier at her door and potential for isolation. Findings: During a record review of Resident 7's admission record dated 7/9/21, showed Resident 7 was admitted to the facility on [DATE]. Resident 7's primary language was Russian. During an observation and interview, on 7/9/21, at 9:30 a.m., a horizontal knee-high, white colored plastic barrier, with a zipper at the center was blocking Resident 7's door. During an interview, on 7/9/21, at 9:41 a.m., and using the interpreter/ translation line, Resident 7 stated she was not aware why the plastic barrier was at her door. Resident 7 pointed at the plastic barrier and stated she felt, very bad to have a plastic barrier at her doorway. During…

    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 · D2021-07-09 · 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 follow the physician order to apply a splint to one of 12 sampled residents (Resident 30)'s left contracted (shortening of the muscle, tendon, or scar tissue causing deformity and possibly permanent disability) arm. This failure had the potential to worsen Resident 30's left arm contracture. Findings: During a record review, with the Licensed Vocational Nurse 3 (LVN 3), on 7/8/21, at 10:32 a.m., Resident 30's physician orders dated 7/4/19 indicated to apply the wrist splint to Resident 30's left upper extremity from 8 p.m.-8 a.m. During an observation, on 7/721, at 7:14 a.m., in Resident 30's room, Resident 30 was sitting in a recliner without a splint applied to the left arm contracture. During an interview, on 7/8/21, at 9:37 a.m., LVN 3 stated she had not seen Resident 30 with a splint for the left arm for the last six months. During a concurrent interview and record review, with the Director of Rehabilitation (DOR), on 7/8/21, at 9:42 a.m., DOR stated by not applying the splint to Resident 30's left…

    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 · D2021-07-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    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 facility document review, the facility failed to provide one resident (Resident 293) a therapeutic diet prescribed by a physician when a medical nutrition shake was not provided as ordered. This failure had the potential to cause a reduction in calorie and/or protein intake intended for the resident resulting in weight loss and/or muscle wasting. Findings: A record review for Resident 293, showed she was admitted to the facility on [DATE]with a diagnoses including but not limited to, schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression, hallucinations, etc.) and Cognitive Communication Deficit (may occur after neurological damage such as a progressive brain disorder, stroke, etc. and the deficit results in difficulty with thinking and how to use language). Physician orders showed Resident 293 was prescribed a Regular diet on 6/14/21 and an Ensure Plus [a medical nutrition shake with concentrated calories and protein 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-09 · tag F0802 — failed to prepare enough nourishing food — isolated
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility document review, the facility failed to ensure the competency of the kitchen staff, who washed dishes, when she did not follow proper hand hygiene and glove use procedures (Cross-reference F 812) and she did not appropriately demonstrate how to check the sanitizer strength for the dish machine. The failure to ensure the competency for one of six staff on dishwashing, hand hygiene, and glove use procedures had the potential to result in cross-contamination of food. Findings: On 7/7/21 at 10:02 a.m., an observation and concurrent interview with Diet Aide 1 (DA 1) and the Dietary Services Supervisor (DSS), showed DA 1 washed soiled resident food dishes from breakfast and handled clean dishes without following current standards of practice as well as facility policy and procedures for proper hand hygiene and glove use (Cross Reference F 812). In addition, DA 1 said she usually washed dishes from breakfast and checked and documented the strength of the chemicals in the dish machine in the morning. She demonstrated how to check the chemical…

    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 · D2021-07-09 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure 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

    Based on observation, interview, and facility document review, the facility failed to prepare food in a manner to conserve nutritive value and that was palatable when the recipe was not followed for pureed broccoli and rice and pureed rice was very gummy and sticky. This failure had the potential to decrease the nutrients in food served and decrease food intake for two residents who received a pureed diet out of a facility census of 47. Findings: Review of the menu served for lunch on 7/7/21 and titled, Daily Spreadsheet showed residents prescribed a Regular texture diet received Red Pepper [NAME] Pilaf and Sauteed Broccoli Florets. Residents that were prescribed a pureed diet received pureed Red Pepper [NAME] Pilaf and pureed Sauteed Broccoli Florets. On 7/7/21 at 11:40 a.m., an observation and concurrent interview with the Dietary Services Supervisor (DSS), showed DSS pureed broccoli in a blender for the lunch meal for residents prescribed a pureed diet. DSS added scoops of cooked broccoli into a blender and a large scoop of butter. The DSS did not measure the butter. He added…

    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 · D2021-07-09 · 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 facility document review, the facility failed to provide one resident (Resident 293) her preferred foods as well as a physician ordered supplement in the consistency and flavor preferred by the resident. This failure had the potential to result in a decreased amount of caloric intake leading to weight loss for 1 of 47 residents residing at the facility. Findings: A record review for Resident 293, showed she was admitted to the facility on [DATE] with a diagnoses including but not limited to, schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression, hallucinations, etc.) and Cognitive Communication Deficit (may occur after neurological damage such as a progressive brain disorder, stroke, etc. and the deficit results in difficulty with thinking and how to use language.) Physician orders showed Resident 293 was prescribed a Regular diet on 6/14/21 and an Ensure Plus [a medical nutrition shake with concentrated calories 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.

    Nutrition and Dietary 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. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2026-04-10 for 41 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to PACS GROUP — 274 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 52.9+2.1 vs chain
Health inspection 4 of 52.5+1.5 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 273 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Anchor Post AcuteAiken, SC 1 of 5Arbor Post AcuteChico, CA 1 of 5Artesia Palms Care CenterArtesia, CA 1 of 5Arvin Post AcuteArvin, CA 1 of 5Ashland Post AcuteAshland, OR 1 of 5Bakersfield Post AcuteBakersfield, CA 1 of 5Beachwood Post-Acute & RehabSanta Monica, CA 1 of 5Brookshire Post AcuteDenver, CO 1 of 5Brushy Creek Post AcuteGreer, SC 1 of 5Buckeye Care And RehabilitationLancaster, OH 1 of 5Carnegie Park Post AcutePittsburgh, PA 1 of 5Cascade Terrace Post AcutePortland, OR 1 of 5Centennial Post AcuteAnchorage, AK 1 of 5Chandler Creek Post AcuteGreer, SC 1 of 5Chehalem Post AcuteNewberg, OR 1 of 5Country Hills Post AcuteEl Cajon, CA 1 of 5Delhi Post-AcuteCincinnati, OH 1 of 5Dublin Post AcuteDublin, OH 1 of 5Edisto Post AcuteOrangeburg, SC 1 of 5Evan Terrace Post AcuteMcMinnville, OR 1 of 5Forest Acres Post AcuteColumbia, SC 1 of 5Grandview Post AcuteCookeville, TN 1 of 5Great Plains Post AcuteWichita, KS 1 of 5Hemet Hills Post AcuteHemet, CA 1 of 5Highland Hills Post AcutePittsburgh, PA 1 of 5Highline Post AcuteDenver, CO 1 of 5Johns Island Post AcuteJohns Island, SC 1 of 5Karcher Post AcuteNampa, ID 1 of 5Kennedy Care CenterLos Angeles, CA 1 of 5Kern River Transitional CareBakersfield, CA 1 of 5Lakeview Post AcuteFlorissant, MO 1 of 5Marion Valley Post AcuteMarion, OH 1 of 5Mirage Post AcuteLancaster, CA 1 of 5Monroeville Post AcuteMonroeville, PA 1 of 5Napa Post AcuteNapa, CA 1 of 5North Royalton Post AcuteParma, OH 1 of 5Northstar Post AcuteCarson City, NV 1 of 5Overland Park Post AcuteOverland Park, KS 1 of 5Pikes Peak Post AcuteColorado Springs, CO 1 of 5Ridgeway Post AcutePetaluma, CA

Showing 40 of 273; lowest-rated first.

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
PROVIDENCE GROUP NORTH LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 06/01/2016
COOK, IANIndividualW-2 MANAGING EMPLOYEEsince 09/01/2022
APT, FREDERICKIndividualCORPORATE OFFICERsince 01/01/2024
JERGENSEN, JOSHUAIndividualCORPORATE OFFICERsince 01/01/2024
MITCHELL, JOHNIndividualCORPORATE OFFICERsince 01/01/2024

1 organizational owner 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.

$11.1M
Net patient revenuemost recent cost report
+11.8%
Operating marginrevenue minus expenses
$585K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 7%Medicare 33%Other / private 59%

This home reported $585K 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

$608per resident / day
operating cost
$18,496per month
≈ monthly operating cost
$690per 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 055085. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-08, 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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