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The Meadows Of Napa Valley

1900 Atrium Parkway, Napa, CA 94559 · Non profit - Corporation · 69 certified beds · (707) 257-7885 Medicare & Medicaid certified

Call the home — (707) 257-7885 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jan 20231 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (22) — 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 5 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Urgent care / clinic
1621 W Imola Ave · (707) 251-4280 · Call to confirm hours
Pharmacy
Rite Aid0.7 mi
1203 W Imola Ave · (707) 255-4218 · Call to confirm hours
Grocery
1491 W Imola Ave · (707) 294-2054 · Call to confirm hours
Park
2300 W Imola Ave · 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 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
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 increased4.2%10.2%15.4%better
Long-stay residents who lose too much weight1.4%4.0%5.4%better
Long-stay residents with a catheter left in their bladder2.9%0.8%0.9%worse
Long-stay residents with a urinary tract infection2.0%1.2%2.0%typical
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 injury4.0%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened23.7%9.8%16.1%worse
Long-stay residents on antianxiety or hypnotic medication4.2%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers5.5%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control17.4%10.2%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table0.0%12.0%17.1%check this — see note marked star below the table
Short-stay residents who newly got an antipsychotic medication1.1%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission24.5%23.0%22.6%typical
Short-stay residents with an outpatient ER visit8.3%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days1.472.251.67better
Long-stay outpatient ER visits per 1,000 resident days1.481.571.80better

* 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.

66.5% 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 251 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.5%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
47.4%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.10hours / resident / day
Speech therapy

Met the expected recovery: 47.4% 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 116 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 43% 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 SNF66.5%CMS range 61.4–71.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.7–12.210.7%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 discharge47.4%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 discharge62.9%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 discharge46.5%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 identified89.4%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 setting100.0%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 discharge96.0%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 stay0.0%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 worsened0.7%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 hospitalization6.6%CMS range 3.9–9.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.801.02Oct 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

0.95
RN hours/ resident / day
0.83
LPN hours/ resident / day
3.04
Aide hours/ resident / day
4.82
Total nurse hours/ resident / day
0.63
RN hoursweekends
41.7%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 69 beds and averages 37.9 residents a day — about 55% occupied, or roughly 31 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.95 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.04 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 4.43 hrs/resident/day on weekends vs 4.98 on weekdays — 11% thinner on weekends. RN hours go from 1.08 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% 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

5
deficiencies at the latest standard inspection (2024-11-08)
4
at the previous standard inspection (2023-01-27)

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.

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

  • Actual harm · Gcited before2023-01-27 · 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 protect one of three sampled residents (Resident 188) from an air mattress that deflated, when the facility was aware that these air mattress types had a risk of deflating. This failure resulted in Resident 188 falling out of bed, and sustaining a right thigh bone fracture. Resident 188 was transferred to the hospital and passed away nine days later. Findings: Review of Resident 188's admission Record indicated Resident 188 admitted to the facility in May 2021 with diagnoses including heart disease and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 188's Minimum Data Set (MDS, an assessment tool), dated 10/26/22, indicated Resident 188 had short and long-term memory problems, and her cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 188 required extensive assistance from two people for bed mobility (how a resident moves…

    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 · D2024-11-08 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure the shower room in hallway 400 of the facility was kept in good working condition when the water in one of the showers did not drain properly and broken tile with sharp edges was found in the shower room floor. These failures increased the potential for residents to experience falls when water pooled and abrasions on their feet. Findings: During an interview on 11/04/24 at 2:14 p.m., Resident 19 stated the water in the 400 hallway shower room did not drain well. Resident 19 showed the Surveyor the shower room she was referring to. During an observation on 11/04/24 between 2:37 p.m. and 2:42 p.m., in the 400 hallway shower room, the surveyor ran the water at full force for 5 minutes. After five minutes, the water created a pool on the shower floor. It took 5 minutes for the water to drain completely. During this observation the shower room floor had broken tile which created sharp edges capable of causing injuries to residents' feet. During a concurrent interview and observation with Maintenance Staff E…

    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 before2024-11-08 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of twelve sampled residents (Resident 19) wore her hearing aids daily to be able to communicate effectively with staff. This finding had the potential for Resident 19 to experience difficulty communicating with others and have feelings of isolation and loss of control. Findings: Record review of Resident 19's Face Sheet indicated she was admitted to the facility on [DATE] with medical diagnoses including cerebral infarction (a process that reduces blood flow to the brain). Record review of a care plan for Resident 19 indicated, Hearing Ability: Adequate with a device .Hearing Appliances: Left and Right Hearing Aid. During a concurrent interview and observation on 11/4/24 at 2:24 p.m., Resident 19 stated she could not understand the speech of the person conducting the bible studies at the facility. Resident 19 stated her hearing aids were not working, and she did not know what was wrong with them. Resident 19 stated she needed 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 · Dcited before2024-11-08 · 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 interview and record review, the facility failed to provide adequate supervision needed to prevent accidents for one resident (Resident 196) of three sampled residents when Resident 196 was left on the toilet and the staff member left Resident 196's room. This failure resulted in Resident 196 sustaining a spinal cord compression (when pressure is applied to the spinal cord causing swelling and restricted blood flow to the nerves and spinal cord) and death. Findings: A review of Resident 196's admission record indicated he was admitted to the facility on [DATE] with medical diagnosis which included: acute on chronic combined systolic and diastolic heart failure (a sudden worsening of a pre-existing condition where the heart struggles to both effectively pump blood out and fill with blood properly), difficulty in walking, need for assistance with personal care, and muscle weakness (lack of muscle strength). A review of Resident 196's Fall Risk Evaluation dated 8/19/24 at 2:03 p.m. indicated within 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 · 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, interviews, and record review, the facility failed to ensure safe storage and disposal of medications when loose units of unidentified pills and an expired bubble pack of narcotics were found in one medication cart. This failure put residents at risk of receiving expired medications that were potentially ineffective and unsafe for use and prevented prompt identification of possible loss and/or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled drugs. Findings: During an observation of Medication Cart 1 on 11/6/24 at 10:09 a.m., four units of loose pills (two white cut pills, one yellow round pill, and one white oval pill) were found among the cart's drawer bins. All four pills were unlabeled and unidentifiable. Further inspection of the cart's narcotic bin revealed a bubble pack affixed with a label that indicated, Oxycodone 5MG TAB . Exp: 11/01/24 . There were five pills left in the bubble pack. During a concurrent interview and observation of the cart on 11/6/24 at 10:28…

    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 before2024-11-08 · 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

    Based on observation, interview, and record review, the facility failed to ensure staff used and understood the need for appropriate Personal Protective Equipment (PPE) for one resident (Resident 5) of five sampled residents for infection control, who had a medical status that required Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes). This failure had the potential to increase the risk of spread of MDROs and other infections among vulnerable residents, staff, and visitors. Findings: During an observation on 11/5/24 at 3:29 p.m., Resident 5 was calling for staff assistance to be transferred from her wheelchair to the toilet. Certified Nurse Assistants (CNA) L and CNA M donned gloves as they entered the room to help Resident 5. A sign posted on Resident 5's door indicated, ENHANCED BARRIER PRECAUTIONS .PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens,…

    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 · Ecited before2023-01-27 · tag F0761 — failed to label and store drugs safely — pattern
    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 did not ensure outdated drugs and biologicals were disposed of properly, when: 1. Two bottles of expired house stock medications (Over-the-counter medications) were found in the facility's medication room stored with other active house stock medications. This had the potential to result in inadvertently administering expired medications to the residents of the facility, which could have caused them harm, or lack of medication therapy. 2. Three controlled medications (Substances regulated by Federal law) were found in the facility's medication carts for two residents that had been discharged more than one week prior to the observation (Resident 139 & Resident 26), stored with other controlled drugs. This had the potential to result in drug diversion among facility staff. 3. Several expired blood collection lab tubes and intravenous tubing (For administration of fluids and medications through a person's veins) were found in the facility medication room. This had the potential to result in inaccurate and contaminated lab…

    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 · D2023-01-27 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an abuse allegation for one of six sampled residents (Resident 14) was reported to the required authorities within the appropriate timeframes established by the Federal regulations. This failure had the potential to result in financial abuse, frustration and emotional harm for Resident 14. Findings: Record review indicated Resident 14 was admitted to the facility on [DATE], with medical diagnoses including Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions) and Chronic Obstructive Pulmonary Disease (A lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible), according to the facility's Face Sheet (Facility demographic). Record review of Resident 14's MDS (Minimum Data Set-A resident assessment tool) dated 12/16/22, indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) was 13, which indicated 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-27 · tag F0732 — isolated
    Post nurse staffing information every day.
    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 post the required daily staffing information timely per the Federal regulations for Skilled Nursing Facilities. This had the potential to result in the inability for residents and visitors to determine if the facility was having staffing shortages, for advocacy purposes. Findings: During a concurrent observation and interview on 1/23/23 at 9:38 a.m., it was noted that the daily staffing information posted in the facility nursing station contained the daily posting from the day before, 1/22/23. There were no staffing postings for 1/23/23 with the current staffing information. Licensed Nurse A, who was present during the observation, confirmed the staffing posting was from yesterday. She stated the front desk clerk was supposed to bring the new one. During an interview on 1/26/23 at 1:39 p.m., Unit Manager D stated visitors were allowed in the facility typically at 9:00 a.m. but sometimes earlier. She stated the Unit Manager Assistant, was supposed to have posted the staffing information for 1/23/23 the night 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-07-02 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview and record review, eight of eight residents stated they did not know how to file a grievance. This failure had the potential to cause residents to feel their needs were not being met. Findings: During group meeting on 6/25/19 at 10:30 a.m., eigt of eight Residents stated they did not know how to file a grievance. Resident 16 stated, to a certain extent, she had a grievance against an aid, she made a complaint to the office staff, they wrote her issue on a piece of paper, had her sign it, but nothing else done. Resident 16 stated she did not have a lot of confidence in complaining and having something done about it. During interview and concurrent record review, with Admissions staff (Admissions keeps logs of grievances filed) on 6/28/19 at 10 a.m., the Grievance Log Book was reviewed. Admissions/SS staff indicated she had no record of Resident 16's complaint, but would check with Resident 16.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-07-02 · tag F0676 — failed to keep up residents' daily-living abilities — pattern
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide the necessary care and services to maintain residents' level of mobility for four of 19 sampled residents (Resident 3, Resident 16, Resident 27, and Resident 49). Which had the potential to result in: Functional decline, reduced likelihood of discharge, and increased risk for depression. Findings: During an interview with Resident 16, on 6/24/19, at 10:54 a.m., she stated she wanted to go home. Resident 16 stated the facility staff did not know what to do for her. When asked if she was getting services to get stronger to assist with her ability to go home, Resident 16 said, yes, but it was not happening. During an interview with Resident 3's family member, on 6/24/19, at 2:30 p.m., he stated Resident 3 was getting therapy help, but it was stopped due to insurance. The family member expressed concern about the lack of services after therapy was completed. He said Resident 3 did well with therapy, but all the progress was lost after that. The family member was visibly frustrated; he said it was a cycle of weakness…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · E2019-07-02 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing services, to one of 16 sampled residents (Resident 27), when the facility did not in-service (train) its Certified Nursing Assistants (CNAs) on resident transfer techniques and did not ensure five of six CNAs were competent to assist Resident 27, who was wheelchair-bound, to transfer from the wheelchair to the toilet. This failure resulted in injury and pain to Resident 27, when in two separate instances CNAs transferred Resident 27 from his wheelchair to the toilet using an improper transfer technique. During one transfer, Resident 27 was placed on the edge of the toilet and pushed back against the toilet seat suffering a skin injury on his buttock, causing him pain and discomfort. During a second transfer, Resident 27 was pushed against the toilet seat and his genitals became entangled in the toilet seat cover causing him extreme pain. Findings: A review of Resident…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-07-02 · tag F0800 — pattern
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide a nourishing and well-balanced diet that met nutritional needs and took into account resident preferences, to two of 16 sampled residents (Residents 3 and 42) when: 1) Resident 3 was not served a vegetable side and a salad side for lunch on 6/24/19; and, 2) Resident 42 was not offered an alternate meal for lunch on 6/24/19. These failures had the potential for Residents 3 and 42's nutritional needs not being met. Findings: 1) A review of the lunch menu for 6/24/19, indicated fish, rice and broccoli. A review of Resident 3's meal ticket for 6/24/19, indicated Resident 3 disliked broccoli and requested a side salad. During an observation on 6/24/19, at 12:40 p.m., Resident 3 was eating lunch in her room, and her tray did not have a side of vegetable or a salad. During a concurrent interview, Resident 3 confirmed (and complained) she had not been served a vegetable side and a side salad, as she had requested. Resident 3 stated she loved salads. During an interview on 6/27/19, at 9:15 a.m., the facility'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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-07-02 · 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 interview, and record review, the facility failed to maintain an infection prevention and control program, that included: Surveillance of infections; a system for recording identified incidents; development and implementation of corrective actions; monitoring corrective actions taken; and antibiotic stewardship. This failure resulted in an increased risk for development and transmission of communicable diseases and infections, in a population of elderly residents with complex medical conditions. Findings: During an interview with Licensed Nurse C, on 6/24/19, at 4:05 p.m., she stated, if a resident in her care had a new symptom of illness or change in mental or physical function, she would call the resident's doctor. LN C stated she would document the change that occurred and the outcome of the conversation with the doctor in the resident's Electronic Medical Record (EMR). LN C stated she would tell the nurse scheduled to relieve her, during the change of shift report. When asked if the facility had requirements regarding what information must be provided to the doctor when…

    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 · E2019-07-02 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement an antibiotic stewardship program. This failure resulted in an increased risk for: Adverse drug events; ineffective treatment from inappropriate antibiotic use; and development of antibiotic-resistant organisms, in a population of elderly residents with complex medical conditions. Findings: During an interview with the Infection Preventionist (IP), on 6/27/19, at 4:12 p.m., she stated the facility had an antibiotic stewardship program. The IP stated reports from laboratory results and new antibiotic order reports, were used in the process. The IP was unable to find any reports showing antibiotic stewardship since she started working at the facility. The IP was unable to provide any documentation which showed interaction with the facility and prescribers, to encourage antibiotic stewardship. During an interview with the Infection Preventionist (IP) and the Administrator, on 6/28/19, at 2:12 p.m., they were unable to provide any documentation…

    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 · D2019-07-02 · 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

    Based on Observation, interview, and record review, the facility failed to ensure one of 16 sampled residents (Resident 20) was treated with dignity and respect, by maintaining and enhancing her self- esteem and self-worth, by involving her preferences and choices of Activities of Daily Living (ADL's), such as showers. The facility failed to consider Resident 20's life style and personal choices disregarding her needs and preferences. Staff failed to implement the established shower scheduled for Resident 20. Staff failed to treat resident 20, equally, when compared to other residents who received showers twice or more in a week. These failures negatively impacted Resident 20's psychosocial well-being, quality of life and quality of care. Findings: During an interview on 6/25/19 at 1:57 p.m., Resident 20 stated, I would like to have more showers than once a week. I showered once a week since last year. Resident 20 stated, I have requested to a Certified Nursing Assistant (CNA, not identified by resident) to get more showers, the CNA said they did not have extra staff. So, I don't…

    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 · D2019-07-02 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely revise and update the comprehensive care plans of two of 16 sampled residents (Residents 25 and 42) when: 1) Resident 25 had an accidental fall on 6/1/19, and her comprehensive fall care plan was not revised and updated to include additional fall prevention interventions. This failure placed Resident 25 at risk of additional falls. 2) Resident 42 acquired a Urinary Tract Infection (UTI) on 6/18/19, and her comprehensive care plan was not revised and updated to include UTI interventions, until 6/26/19. This failure placed Resident 42 at risk of not receiving timely nursing interventions for her UTI. Findings: 1) A review of Resident 25's face sheet indicated she was 78 years-old and was admitted to the facility on [DATE], with diagnoses which included heart failure, edema, hypertension, chronic kidney disease stage five, atrial fibrillation, muscle weakness and unsteadiness on her feet. A review of Resident 25's Incident Reports indicated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-02 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 25) received treatment and care, in accordance with professional standards of practice, when the facility administered Carvedilol (a blood pressure medication) to Resident 25, without food, on an empty stomach. The Food and Drug Administration (FDA) recommends administering Carvedilol with food to slow the rate of absorption and prevent sudden loss of blood pressure, which can result in dizziness, loss of consciousness and falls. Approximately 30 minutes after being given Carvedilol on an empty stomach, Resident 25 fainted and fell, injuring her knee and face. Findings: A review of Resident 25's face sheet indicated she was 78 years-old and was admitted to the facility on [DATE], with diagnoses which included heart failure, edema, hypertension, chronic kidney disease stage five, atrial fibrillation, muscle weakness and unsteadiness on her feet. During an observation on 6/25/19, at 4:29 p.m.,…

    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 · D2019-07-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility filed to provide preventative measures, consistent with professional standards of practice, to one of 16 residents (Resident 1). The facility failed to provide treatment consistent with professional standards of practice to an existing surgical wound to the right hip and right knee. The facility failed to ensure Resident 1 did not develop avoidable skin injuries, failed to identify Resident 1 was at risk for skin injuries and failed to provide interventions to prevent further skin injuries. These failures resulted in Resident 1 acquiring five skin injuries to his left leg, nine days after admission. Findings: During an observation and concurrent interview on 6/29/19 at 10 a.m., Resident 1 was lying down in his bed with his right knee immobilizer (a long divide to keep knees straight and prevent knees from moving freely, with Velcro attachments) in place to his right knee, and his right leg was raised on pillows. The left leg was bare, and skin injuries were covered with a total of five dry bandages. Resident 1 stated he…

    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 before2019-07-02 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to label drugs according to professional principles, when the facility labeled one bottle of lorazepam (an anxiolytic medication) with an opened date which was unclear and did not label another bottle of lorazepam with the date it had been opened. The bottles of lorazepam indicated on their label they expired 90 days after being opened. The facility's failure to properly date the lorazepam bottles with the date they were opened, had the potential for residents to receive expired lorazepam. Findings: During an observation of the facility's main medication room on [DATE], at 9:25 a.m., with the Director of Nursing (DON), there were two opened bottles of Lorazepam Intesol 30 ml (milliliters). One bottle was marked as having been opened on, 6/17, and another bottle did not have the date it was opened. Both bottles indicated on their labels they were valid for 90 days after opening. During a concurrent interview, the DON was asked what the date,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-02 · tag F0813 — isolated
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to implement its policy on food brought into the facility by family and visitors, for one un-sampled resident (Resident 52), when Resident 52 had fruit in her room, not provided by the facility, which was not labeled with Resident 52's name, room number and date it was brought in. This failure had the potential for Resident 52 to consume unsafe food. Findings: During an observation on 6/24/19, at 11:45 a.m., there were bags of cherries, grapes and strawberries next Resident 52's bed. The bags containing the fruit were not labeled with Resident 52's name, room number or date they were brought in. During an observation and interview on 6/24/19, at 12:20 a.m., the Director of Nursing (DON) confirmed the fruits were not provided by the facility and were not labeled with Resident 52's name, room or date. The DON removed the fruit from Resident 52's room. A review of facility policy titled, Food Brought Into Facility by Family and Visitors, last revised 3/2018, indicated: Brought-in food must be covered, labeled 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-02 · 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

    Based on observation, interview and record review, the facility failed to maintain accurate medical records for one of 16 sampled residents (Resident 42), when the facility documented Resident 42 ate 90% of her lunch on 6/24/19, when in fact, Resident 42 ate less than 25% of her lunch. This failure resulted in Resident 42's medical record not properly representing the health conditions of Resident 42. Findings: During an observation on 6/24/19, at 1:05 p.m., Resident 42's lunch tray was removed from her room to a meal cart on the hallway, by staff. An inspection of Resident 42's lunch tray indicated less than 25% of the food had been consumed. During an interview on 6/25/19, at 8:45 a.m., Resident 42 reported she did not like the food served for lunch on 6/24/19, and ate very little of her tray's contents. A review of Resident 42's meal consumption record for 6/24/19, Daily Charting for: Monday, June 24, 2019, indicated Resident 42 consumed 90% of lunch on 6/24/19. A review of facility policy titled, Nursing Services Documentation, last revised 3/2015, indicated: It is the policy 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.

    Resident Assessment and Care Planning 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 PACIFIC RETIREMENT SERVICES — 10 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 54.6+0.4 vs chain
Health inspection 5 of 54.3+0.7 vs chain
Staffing 5 of 54.7+0.3 vs chain
Quality measures 4 of 54.1≈ chain avg
The other 9 homes this chain runs (chain average 4.6★, 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 / managerTypeRoleSince
BBVA USAOrganization5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTERESTsince 07/14/2016
PANCHESSON, WAYNEIndividualW-2 MANAGING EMPLOYEEsince 04/16/2001
ALLEN, RAYMONDIndividualCORPORATE DIRECTORsince 04/15/2013
LINK, RAYMONDIndividualCORPORATE DIRECTORsince 05/01/2008
OLIVER, ROBINIndividualCORPORATE DIRECTORsince 05/01/2006
OLSON, TERRYIndividualCORPORATE DIRECTORsince 05/01/2012
REED, DAVIDIndividualCORPORATE DIRECTORsince 05/19/2013
WORTH, GERALDIndividualCORPORATE DIRECTORsince 06/01/2002
SHOLTY, ERICIndividualCORPORATE OFFICERsince 05/27/2018
PRS MANAGEMENT INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 08/01/1999

CMS files one row per role, so the 11 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

$13.5M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 18%Medicare 10%Other / private 72%

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$1,134per resident / day
operating cost
$34,478per month
≈ monthly operating cost
$399per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 555639. 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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