Fruitvale Healthcare Center
3020 East 15th Street, Oakland, CA 94601 · For profit - Partnership · 140 certified beds · (510) 261-5613 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (24% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2025
- it has 1 actual-harm citation
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $82,691 in federal fines (most recent 2024-12-11)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 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 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.5% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.4% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.4% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.0% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 3.3% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.4% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.7% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 1.5% | 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 table | 10.7% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 11.5% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.5% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.28 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.57 | 1.57 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 59 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 39% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.7%CMS range 38.0–61.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.3%CMS range 6.3–13.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 0.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 7.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.4%CMS range 5.0–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.13 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 140 beds and averages 134.5 residents a day — about 96% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.09 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.89 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.91 hrs/resident/day on weekends vs 4.17 on weekdays — 6% thinner on weekends. RN hours go from 0.49 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 24% is below 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
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.
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.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · Gcited before2024-12-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 2) received adequate supervision and assistance device to prevent falls when Certified Nursing Assistant (CNA) 1 transferred Resident 2, who was totally dependent on staff for activities of daily living, from wheelchair to bed without another staff present and without using a Hoyer lift (interchangeably used with mechanical lift, uniquely designed electronically operated patient lift to transfer patients between two surfaces, for example from their bed to another surface such as a wheelchair or couch). This failure resulted in Resident 2's fall and transfer to the hospital for a four-day hospitalization for closed displaced subtrochanteric fracture of the right femur (broken bone specifically in the area just below the hip joint, where the fractured pieces are significantly out of alignment, but the skin over the fracture site remains intact, making it a non-open wound). Findings: During a review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-17 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pain management was provided, consistent with the comprehensive resident-centered plan of care and professional standards of practice for one of two sampled residents (Resident 2) when a scheduled pain medication was not administered according to the physician's order.This failure had the potential to result in ineffective pain management.During a review of Resident 2's Resident Face Sheet (RFS), the RFS indicated Resident 2 was admitted to the facility in August 2025 with diagnoses that included systemic lupus erythematosus (a chronic autoimmune disease, causing inflammation and tissue damage, with symptoms like joint and muscle pain) and chronic pain syndrome.During a review of Resident 2's Minimum Data Set (MDS, an assessment tool used to direct resident care) assessment dated [DATE], the MDS indicated Resident 2 received scheduled and prn (given as needed) pain medication daily, and occasionally experienced pain rated at four out of 10 (zero…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-09 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect one of two sampled residents (Resident 1) from physical abuse when Resident 2 hit Resident 1 ' s right shin with a front wheel walker (a walker is an assistive device used to aid in walking, providing stability and reducing weight bearing on the lower extremities of an individual). This failure resulted in Resident 1 sustaining redness on his right leg, pain, and a transfer to Acute Care Hospital (ACH 1) for follow-up care. Findings: During a record review of Resident 1 ' s Face Sheet (A Face Sheet is a summary document that provides essential resident information), the record showed Resident 1 was admitted to the facility in November 2021. The record indicated Resident 1 had diagnosis of Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified Dementia (a condition that affects memory, thinking, and reasoning, interfering with daily life). During a record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-24 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to provide food at an appetizing temperature, which affected 1 (Resident #32) of 4 residents reviewed for food. Findings included: An undated facility policy titled, Meal Service, indicated, Residents will receive their food at appropriate temperatures and an appetizing appearance; therefore, trays may be set up ahead of time with non-perishable items only. A Resident Face Sheet revealed the facility admitted Resident #32 on 11/04/2014. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/01/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #32 was interviewed on 10/21/2024 at 11:42 AM. Resident #32 stated the food at the facility was not always served hot, and if they were the last one served, the food was cold. During an observation on 10/23/2024 at 8:19 AM, staff passed meal trays on Station 4. The last tray on the food cart was removed from the meal cart at 8:27…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for 1 (Resident #17) of 4 residents reviewed for pressure ulcers. The facility also failed to ensure staff changed gloves and performed hand hygiene between dirty and clean tasks for 1 (Resident #14) of 1 resident observed during incontinence care. Findings included: 1. An undated facility policy titled, Enhanced Barrier Precautions (EBP) revealed, 1. EBP shall be used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that may result in transfer of MRDOs [multidrug-resistant organisms] to staff hands and clothing. 2. EBP are indicated for residents with any of the following, to include b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-06 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being when psychiatric and mental health services were not provided to treat mental and substance use disorders. This failure had the potential to result in significant distress from unresolved psychosocial and mental health issues. Findings: During a review of Resident 1's Resident Face Sheet, the Resident Face Sheet indicated Resident 1 was admitted to the facility in January 2024 with diagnoses that included schizophrenia (serious mental health condition that affects how people think, feel and behave), auditory hallucinations (sensory perceptions of hearing in the absence of an external stimulus) and psychoactive substance abuse (strong desire or sense of compulsion to take psychoactive substance, various natural or synthetic compounds that cause changes in thoughts, emotions and behavior). During a review of Resident 1's Hospitalists…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-29 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the right to be free from verbal abuse for one of three sampled residents (Resident 1) when a staff member used profanity while providing toileting care to Resident 1. This failure resulted in Resident 1 feeling disrespected by the facility staff. Findings: During a review of the Face Sheet (a document used to communicate basic information about a resident) for Resident 1, undated, the record indicated Resident 1 was admitted to the facility in May 2022 with generalized weakness and hemiplegia (the loss of muscle function on one side of the body) affecting the dominant side of the body. During a review of the Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) for Resident 1, dated 2/27/24, the record indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-08 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from verbal abuse when Certified Nursing Assistant (CNA) yelled at Resident 1 I will knock you the 'F' out during a verbal altercation. This failure had the potential to result in psychosocial harm. Findings: During a review of Resident 1's Face Sheet, undated, the Face Sheet indicated Resident 1 was admitted to the facility in January 2024 with diagnoses that included vascular dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior) with behavioral disturbance, adult failure to thrive and opioid dependence (Physical and psychological reliance on opioids, a substance found in certain prescription pain medications and illegal drugs like heroin). 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 1/19/24, the MDS 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.
- Potential for harm · Dcited before2024-02-15 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices when a Certified Nursing Assistant (CNA) did not wear gloves and a gown before entering a positive COVID room and did not perform hand hygiene after exiting the room. This failure had the potential for the spread of germs and infection. Findings: During an observation on 2/15/24 at 1:12 p.m. in station 1, there was a transparent plastic shield with a zipper at the door of room [ROOM NUMBER]. The door was wide open behind the shield. There was signage on the door indicating transmission-based precautions for COVID. On the left, attached to the door, were Personal Protective Equipment (PPE - disposable protective gowns, gloves, etc.,). room [ROOM NUMBER] had two residents who were in isolation for COVID 19. CNA 1 was entering room [ROOM NUMBER]. CNA 1 unzipped the transparent plastic shield, entered the room, and did not wear gloves and a gown. CNA 1 proceeded to Bed B, delivered a food tray to 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.
- Potential for harm · Ecited before2021-12-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure sanitary conditions in the kitchen when the solution in two red buckets that contained quaternary ammonium (Quat-a disinfectant) had not been checked and changed for two days. This deficient practice had the potential to spread food borne illnesses. Findings: During the initial kitchen tour observation on 12/6/21 at 8:29 a.m., two red buckets that contained a dark, cloudy liquid were observed on the stainless steel counter top near the three way sink. During an interview and concurrent record review with the Dietary Manager (DM) on 12/6/21 at 8:33 a.m., DM stated the red buckets were sanitation buckets that contained quaternary ammonium solution. DM reviewed the Quat sanitizer log for the red sanitation buckets and stated the log indicated the Quat sanitizer were last checked and changed on 12/4/21 at 6:30 p.m. DM stated the Quat sanitizer in the red buckets should be checked and changed every four hours to prevent the spread of germs. DM stated the Quat solution in the red buckets was used to wipe down…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide housekeeping services and linen services to maintain a clean home-like environment for two of 36 sampled residents (Resident 110 and Resident 128). The wall and ceiling in Resident 128's room was dirty with a reddish-brown splatter stain, and the sheets on Resident 110's bed were thin and full of holes. This deficient practice resulted in Resident 110 and Resident 128 not living in a homelike environment. Findings: 1. During a review of the Minimum Data Set (MDS - a resident assessment tool used to guide care), for Resident 110, dated 11/15/21, the MDS indicated Resident 110 was admitted to the facility on [DATE]. During a review of Section C 0500 of the MDS, the MDS indicated Resident 110 had a Brief Interview for Mental Status (BIMS, a cognitive assessment tool) of 12 (moderate cognitive impairment). During an interview with concurrent observation with Resident 110 on 12/6/21 at 10:16 a.m., Resident 110 stated they rarely change…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · D2021-12-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide services to prevent contractures from worsening for one (Resident 111) of 16 sampled residents. This failure had the potential for Resident 111 to develop limitations in range of motion and decrease theability to participate in activities of daily living. Findings: During a review of the Minimum Data Set (MDS - a resident assessment tool used to guide care) for Resident 111, dated 8/16/21, the MDS indicated Resident 111 was admitted to the facility on [DATE] with diagnoses to include high blood pressure, diabetes, stroke, dementia, and chronic kidney disease. During a review of Section C 0500 of the MDS, the MDS indicated Resident 111 had a Brief Interview for Mental Status (BIMS, a cognitive assessment tool) of 03 (severe cognitive impairment). Section O 0500 of the MDS indicated Resident 11 did not receive passive or active range of motion during the assessment period. Resident 111 also did not use a brace or splint. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 36 sampled residents (Resident 231), was given foley catheter care every eight hours according to Medical Doctor (MD) orders. This deficient practice had the potential to result in urinary tract infections for Resident 231. Findings During a review of Resident 231's undated facesheet (a document that gives a resident's information at a quick glance), the facesheet indicated Resident 231 was admitted on [DATE] with multiple diagnoses including, neuromuscular dysfunction of the bladder (a lack of bladder control due to brain, spinal cord, or nerve problems), urinary tract infection (UTI), paraplegia (paralysis of the lower legs and body), and encephalopathy (any brain disease that alters brain function or structure). During a review of Resident 231's Physician orders, dated 11/24/2021, the Physician orders indicated, Indwelling Foley catheter care q (every) shift with soap and water, and, Monitor urine output for signs and symptoms of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-10 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility to assist two (Resident 55 and 117) out of 36 sampled residents in obtaining prescription glasses. This failure had the potential to result in Resident 55 and Resident 117's limitation in performing their activities of daily living due to their inability to see their surroundings clearly. Findings: During an interview on 12/6/21, at 9:14 a.m. with Resident 117, Resident 117 stated that she had been waiting for her eyeglasses. Resident 117 was told it would take 6-8 weeks, but she has been waiting for three and a half months. During an interview on 12/13/21, at 7:55 a.m., with Resident 117, Resident 117 stated that she can see but she can't read without her eyeglasses and that they have not updated her about the status of her eyeglasses. During an interview on 12/6/21, at 11:42 a.m. with Resident 55, Resident 55 stated that he had seen an eye doctor while he was in the facility, he was prescribed an eyeglass to which they said would arrive in 2-3 weeks and it has been four months already and it still has not been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-10 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to monitor the signs and symptoms of bleeding for one of one sampled residents (Resident 43) that received heparin (anticoagulant-a medicine used to decrease the clotting ability of the blood). This deficient practice had the potential to result in Resident 43's care needs not being addressed and delay initiation of appropriate treatment in a timely manner. Findings: Review of Resident 43's undated Facesheet (a document that provides resident specific information at a quick glance), indicated Resident 43 was admitted to the facility on 9/16//21 with multiple diagnoses that included end stage renal disease (the gradual loss of kidney function) and dependence on renal dialysis (a blood purifying treatment given when kidney function is not optimum. This treatment is sometimes given via a arteriovenous [AV-a connection between an artery and vein] shunt). Review of Resident 43's physician's orders dated 9/1/21-9/30/21, indicated Resident 43 had an order from 9/16/21 to 11/18/21 for heparin (porcine) solution; 5,000 unit/ml; amt: 1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-03-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for three of four sampled residents who were smokers (Residents 6, 73 and 126), the facility failed to ensure residents' environment were free from accident hazard when smoking materials were not stored securely. This failure had the potential to result in accidents such as cigarette burns and fire hazard in resident rooms where smoking materials were stored. Findings: 1. During an observation and interview with Resident 126 on 3/4/19 at 12:30 p.m., Resident 126 stated facility allowed for cigarettes and lighters to be stored at the bedside or in residents' pockets. Resident 126 pulled out a disposable cigarette lighter tucked inside an empty cigarette box from his pocket and stated he had always kept his cigarettes and lighters on him and that the facility knew about it since admission. Review of Resident 126's clinical record indicated Resident 126 was admitted on [DATE]. Resident 126's Minimum Data Set (MDS, an assessment tool used to direct resident care)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-03-07 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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, for two of 27 sampled residents (Resident 133 and 128), facility failed to ensure its medication error rate did not exceed five percent. There were two medication errors out of 24 opportunities for error that totaled 8.33%. 1. For Resident 133, Licensed Vocational Nurse (LVN) 2 did not give instructions on how to use budesonide formoterol (an inhaled medication used to treat asthma) inhalation prior to administration of the medication. 2. For Resident 128, LVN 1 did not give instructions for use prior to administration of Incruse Ellipta (an inhaled medication that relaxes muscles of the airways making it easier for an individual to breathe). This failure had the potential to result in Residents 133 and 128 not getting the maximum therapeutic benefits of the medication. Findings: 1. Review of the clinical record indicated Resident 133 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure (not able to take in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-03-07 · tag F0800 — patternProvide 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 residents with palatable meals when hot meals were served warm and cold meals were served warm. This failure resulted in residents not receiving their meal preferences, lost appetite and not wanting to eat their meal. Findings: In a group interview on 3/4/19 at 10:00 a.m. Residents 7, 17, 21, 23, 30, 53, 71, and 103 all stated that the meals were usually served cold. Resident 30 stated that his meals were always chicken and it was always cold. Resident 30 stated that he had diabetes (high blood sugar) and because the meal was cold he did not want to eat it. Resident 53 stated that sometimes the juices were warm. Resident 53 stated when they served him cold food he would lose appetite and not wanting to eat his meal. During a food serving observation and concurrent interview with the Dietary Aide (DA2) on 03/03/19 at 10:09 a.m., DA2 checked the temperature in a tray just taken out from the food cart. DA2 confirmed the temperature of the following food items as follows: In Resident 82's tray, Coffee 139…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-03-07 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
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 their policy on the times they serve meals to their residents. This failure resulted in hungry residents not having a substantial meal on time. Findings: During a Kitchen tour observation on 3/3/19 at 9:35 a.m., the cook and two Dietary Aides were plating food for resident's breakfast. Dietary Aide (DA1) stated that breakfast was being served late today. In a separate observation on 3/3/19 at 10:09 a.m., the last cart came out of the kitchen. In an interview on 3/3/19 at 10:30 a.m., Dietician (RD1) stated that the facility was aware of the late meals and that it has been a quality assurance issue the facility's been trying to resolve. In a group interview on 3/4/19 at 10:00 a.m. Residents 7, 17, 21, 23, 30, 53, 71, and 103 all stated that breakfast, lunch and dinner were constantly served late. The group added that breakfast was served mostly around 10:00 a.m. Resident 30 stated that he was tired of the facility serving them late…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-03-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. several food items were expired, unlabeled, and undated; 2. two of two ice machines were not cleaned and maintained per facility's policy; 3. staff were not monitoring freezer temperature; 4. Dishwasher (DW1) did not wear hair net while working inside the kitchen; 5. staff were using dishwasher sanitizer test strips with no expiration dates. These failures had the potential to cause food contamination or food borne illness. Findings: 1. During an observation and concurrent interview on 3/3/19 at 8:37 a.m. the following were observed: a. In the kitchen refrigerator, eleven bars of [NAME] Margarine did not have a used by dates or expiration dates. Two dozen eggs did not have a used by date or expiration date. b. In the dry storage room, a bin of flour had a prep date of 1/24/19, no used by date; a bin of brown sugar had no label and no used by date; a bin of barley had a used…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-03-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the personal care equipment (wash basin) for residents in three rooms (room [ROOM NUMBER], 106 and 107) were labeled and stored at the resident's bedside cabinet. This failure resulted in residents at risk for contacting disease-causing organism. Findings: During the initial tour of the facility on 3/3/19 between 8:10 a.m. and 8;30 a.m., the following were observed: A. In room [ROOM NUMBER]'s bathroom, the wash basin was on the floor underneath the sink. B. In room [ROOM NUMBER]'s bathroom, the wash basin was on the floor underneath the sink. C. In room [ROOM NUMBER]'s bathroom, the wash basin was on the floor underneath the sink. During an interview with Certified Nursing Assistant (CNA1) on 3/6/19 at 1:30 p.m., CNA 1 stated, We don't put bedpans, wash basins, and urinals on the floor, we should label these items with the resident's name, after we are done with the care, we rinse, dry and store them in the drawer at bedside table.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-03-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of one sampled resident (Resident 49) who complained of abuse, the facility failed to ensure Resident 49 was free from physical abuse when Resident 100 threw water at Resident 49. Resident 49 had behavioral issues, that potentially provokes physical retaliation from other residents, that were not addressed appropriately by the facility. This failure had the potential to result in Resident 49's emotional distress and future incidents of abuse from other residents in reaction to Resident 49's verbal aggression. Findings: Review of the clinical record indicated Resident 100 was admitted to the facility on [DATE]. Resident 100's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/4/19 indicated Resident 100 had good recall of spoken words and knew the year, month and day during the assessment with intact cognition. The MDS also indicated Resident 100 had verbal behavior symptoms i.e. threatening others, screaming and cursing at others that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-03-07 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the Ombudsman of residents discharges for three of 27 sampled residents (19, 35 and 129). This failure had the potential to result in residents 19, 35 and 129 not being afforded the services of the Ombudsman. Findings: Review of the admission Record indicated Resident 19 was admitted to the facility with multiple diagnoses that included acute ischemic heart disease (heart problems caused by narrowed heart arteries). Further review indicated Resident 19 was discharged to the hospital on 1/23/19. Review of Resident 19's notes indicated the facility did not notify the ombudsman's office of Resident 19's discharge to the hospital. Review of the admission Record indicated Resident 35 was admitted to the facility with multiple diagnoses that included anemia (the blood lacks enough healthy red blood cells or hemoglobin). Further review indicated Resident 35 was discharged to the hospital on 2/19/19. Review of Resident 35's notes indicated the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-03-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of 27 sampled residents (Resident 133) received treatment and care as the physician's order when Resident 133 was taking oxygen four liter per minute per nasal [NAME] and the physician's order was for two liters per minute. As a result of this deficient practice Resident 133 was at risk for physical damage due to oxygen toxicity. Findings: Review of Resident 133's face sheet indicated Resident 133 was admitted to the facility on [DATE] with multiple diagnosis including COPD (chronic obstructive pulmonary disease - obstruction of lung airflow that interferes normal breathing). During an observation on 3/4/19 at 10:02 a.m. Resident 133 was taking four-liter oxygen per minute per nasal [NAME]. During an interview with RN (Registered Nurse)1 on 3/4/19 at 10:02 a.m. RN 1 confirmed that the oxygen was on 4 liters and stated Resident 133 had COPD and high oxygen can make Resident 133's breathing situation worse. A review of Physician…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-03-07 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide pain management for one (Resident 105) of 27 sampled residents, when: 1. a routine pain medication was not reordered; 2. a pain medication available at the facility was not used. These failures resulted in unnecessary pain and suffering which affected Resident 105's ability in maintaining his highest practicable physical, mental, and psychosocial well-being. Findings: 1. Review of the admission record indicated that Resident 105 was admitted on [DATE] with multiple diagnosis including pressure ulcer and chronic pain. In an interview with the Director of Nurses (DON) on 3/5/19 at 9:30 a.m., DON stated that Resident 105 was consistently complaining of generalized body pain. DON added that Resident 105 was on a routine dose of morphine. Review of the Pain administration history dated February 2019 indicated that Resident 105's pain was between 3 to 7. According to the facility's pain Scale: (0-10) Behavior indicators: 1 - Crying, 2 -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$82,691 in federal fines across 15 penalties.
- $8,947 — penalty dated 2024-12-11
- $14,113 — penalty dated 2023-12-26
- $4,587 — penalty dated 2023-11-13
- $4,587 — penalty dated 2023-11-06
- $4,587 — penalty dated 2023-10-30
- $4,587 — penalty dated 2023-10-23
- $4,587 — penalty dated 2023-10-17
- $4,587 — penalty dated 2023-10-10
- $4,587 — penalty dated 2023-10-02
- $4,587 — penalty dated 2023-09-25
- $4,587 — penalty dated 2023-09-18
- $4,587 — penalty dated 2023-09-11
- $4,587 — penalty dated 2023-09-05
- $4,587 — penalty dated 2023-08-28
- $4,587 — penalty dated 2023-08-21
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 MARINER HEALTH CARE — 17 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.6 | +1.4 vs chain |
| Health inspection | 5 of 5 | 2.9 | +2.1 vs chain |
| Staffing | 4 of 5 | 4.2 | -0.2 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 16 homes this chain runs (chain average 3.6★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GRANCARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/28/2013 |
| MARINER HEALTH CARE, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/28/2013 |
| MHC HOLDING COMPANY | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/28/2013 |
| MHC WEST HOLDING COMPANY | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/28/2013 |
| NATIONAL SENIOR CARE, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/28/2013 |
| GRUNSTEIN, EMILY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/06/2019 |
| PERSINGER, NICHOLAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/26/2024 |
| SARCAUGA, DENNIS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/06/2025 |
| TINGZON, DAVE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/06/2023 |
| FRUITVALE HOLDING COMPANY GP, LLC | Organization | GENERAL PARTNERSHIP INTEREST | — | since 08/28/2013 |
| GC HOLDING COMPANY 3, LLC | Organization | LIMITED PARTNERSHIP INTEREST | — | since 08/01/2022 |
| DHUGGA, GURPREET | Individual | ADP OF THE SNF | — | since 09/01/2022 |
CMS files one row per role, so the 14 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.6M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555358. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-24, 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 →
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