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Oakland Healthcare & Wellness Center

3030 Webster Street, Oakland, CA 94609 · For profit - Limited Liability company · 98 certified beds · (510) 250-8000 Medicare & Medicaid certified

Call the home — (510) 250-8000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 27 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3315 Broadway Fl 1 · (833) 936-7846 · Call to confirm hours
Pharmacy
3009 Broadway · (510) 285-0213 · Call to confirm hours
Grocery
2900 Broadway · (510) 465-5649 · Call to confirm hours
Park
3239 Kempton Ave · (510) 238-7275 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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 fell from 5 to 3 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 rating3★
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 increased3.5%10.2%15.4%better
Long-stay residents who lose too much weight2.5%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.3%1.2%2.0%better
Long-stay residents with depressive symptoms12.3%7.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.3%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened2.8%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication1.4%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers7.5%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control5.0%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 table7.3%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine92.6%93.2%79.4%better
Short-stay residents rehospitalized after admission18.0%23.0%22.6%better
Short-stay residents with an outpatient ER visit17.6%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.662.251.67typical
Long-stay outpatient ER visits per 1,000 resident days1.181.571.80better

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.

53.7% 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 116 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.7%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
53.2%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 53.2% 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 77 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF53.7%CMS range 43.7–62.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.8–12.910.7%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 discharge53.2%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 discharge52.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.6%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 identified66.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.2%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 discharge88.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened1.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 4.3–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.231.02Oct 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

0.67
RN hours/ resident / day
0.97
LPN hours/ resident / day
2.52
Aide hours/ resident / day
4.16
Total nurse hours/ resident / day
0.54
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 98 beds and averages 94.7 residents a day — about 97% occupied, or roughly 3 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 4.16 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 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 3.82 hrs/resident/day on weekends vs 4.29 on weekdays — 11% thinner on weekends. RN hours go from 0.72 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

6
deficiencies at the latest standard inspection (2026-01-15)
10
at the previous standard inspection (2024-07-25)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Potential for harm · Ecited before2026-01-15 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM is one aspect of exercise important for increasing or maintaining joint function) for three of four sampled residents (Residents 6, 75, and 26).This failure had the potential to result in further decline in Residents 6, 75, and 26's ROM. 1.A review of Resident 6's admission record (AR), undated, indicated Resident 6 was admitted on [DATE] with diagnoses that included hemiplegia (paralysis affecting one side of the body, often the face arm, leg, usually from brain or spinal cord injury), diabetes, and repeated falls. A review of Resident 6's Minimum Data Set (MDS - an assessment screening tool used to guide care) dated 11/7/25 indicated Resident 6 with functional limitations in range of motion on one side of the upper extremity (shoulder, elbow, wrist, hand) and one side of the lower extremity (hip, knee, ankle, foot). A review of the record of the last…

    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 · Ecited before2026-01-15 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and record review, the facility failed to store food in accordance with professional standards for safety when: Kitchen staff had uncovered facial hair while in the kitchen.Beyond use by date food items were stored in the kitchen refrigerator.Unlabeled, undated and expired food items were stored in the resident refrigerator. These failures had the potential for contamination of food resulting in food borne illness for the 97 residents who lived at the facility. During an observation on 1/12/26, at 9:24 a.m., the Dietary Supervisor (DS) had uncovered facial hair while in the facility kitchen. During an observation on 1/12/26, at 9:42 a.m., the kitchen refrigerator had cranberry sauce with a use by date of 12/27/25 and salad dressing with a use by date of 12/30/25. During an observation on 1/12/26, at 10:18 a.m., the resident refrigerator had a smoothie with an expiration date of 1/5/26, one pack of ready to eat chicken not labeled with resident name or date, one unknown food item not labeled with date, and one unknown food item not 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 · D2026-01-15 · 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 two of 25 sampled residents (Residents 30 and 95) received nail care and shaved in accordance with their preferences.This failure had the potential to cause Residents 30 and 95 to feel embarrassed and undignified. During a review of Resident 30's admission Record, printed 1/15/26, the Record indicated Resident 30 was admitted to the facility in December 2025 with a diagnosis of need for assistance with personal care. During a review of Resident 30's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve is an indication of moderate impairment.), dated 12/9/25, the record indicated Resident 30's BIMS score was 12. During a concurrent observation and interview on 1/12/26, at 11:41 a.m., with Resident 30, Resident 30 was observed with facial hair and long dirty finger nails. Resident 30 stated staff did not offer to shave or cut and clean…

    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 · D2026-01-15 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 timely assessment and intervention to one of two sampled residents (Resident 95) when Resident 95 had a significant change in condition related to weight loss. This failure placed Resident 95 at risk for malnutrition (body does not receive enough nutrients), dehydration (insufficient body fluid), decline in functional status, and emotional discomfort. During a review of Resident 95's admission Record (AR), printed on 1/13/25, the AR indicated Resident 95 was admitted to the facility in October 2025 with diagnoses of cerebral infarction (brain tissue dies because it doesn't get enough blood) and depression (a serious mood disorder causing persistent sadness, loss of interest in enjoyable activities, and impacts daily life).During a review of Resident 95's Care Plan, revised on 10/27/25, the Care Plan indicated Resident 95 had potential nutritional problems related to diagnoses and body weight of 264 pounds (lbs.). The Care Plan further indicated a goal for Resident 95 to remain within 5% of 264 lbs. and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to identify significant weight loss and implement interventions for two out of four sampled residents (Resident 28 and 95).These failures had the potential to result in continuous, unplanned weight loss for Residents 28 and 95.1.During a review of Resident 28's admission Record, dated 1/15/26, the admission Record indicated Resident 1 was admitted in the facility on 12/25/25 with an admission diagnosis of nontraumatic chronic subdural hemorrhage (bleeding under the brain's outer covering, occurring without significant head injury). During an interview on 1/12/26 at 11:46 a.m. with Resident 28, Resident 28 stated having difficulty chewing food and losing weight. During a concurrent interview and record review on 1/15/26 at 9:19 a.m. with Restorative Nursing Assistant (RNA) 1, Resident 28's Weekly Weights, dated 12/29/25 and 1/5/26 were reviewed. The Weekly Weights indicated, Resident 28's weight the week of 12/29/25 was 134.4 pounds (lbs.), and the week of 1/5/26 was 123.2 lbs. RNA 1 stated giving a copy of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-15 · tag F0836 — isolated
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report an unusual occurrence report within 24 hours to the California Department of Public Health (CDPH) when one of two sampled residents (Resident 4) had an unwitnessed fall and sustained lacerations (cuts) on the back of the head after being found and was sent to acute care hospital.This failure delayed regulatory oversight and placed Resident 4 at increased risk of repeated falls and additional injury, while also putting other residents at risk for similar harm. During a review of Resident 4's admission Record printed on 1/15/26, the admission Record indicated Resident 4 was admitted to the facility in November 2025 with diagnoses of right femur fracture (broken leg), abnormalities of gait and mobility and mild cognitive impairment. During an interview on 1/12/26 at 3:23 p.m. with Resident 4, Resident 4 stated experiencing a recent fall that resulted in a laceration to the back of the head requiring two staples (metal clips used to close the wound). Resident 4 stated the fall occurred in the shared bathroom when a…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-03 · 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

    Based on observation, interview and record review, the facility failed to ensure 90 of 90 sampled residents were prevented from unauthorized visitor entry or resident exit from the facility when facility staff failed to close the alarmed emergency exit back door and arm the emergency exit alarm for 35 minutes during the evening shift. This failure had the potential to result in unauthorized visitor entry and/or unwitnessed resident elopements potentially resulting in resident injury. Findings: During an observation of the alarmed emergency exit back door on 10/17/24, at 1:00 p.m., the alarmed emergency exit back door was opened; there was no audible alarm. The door led to an access ramp with direct access to public streets. The access ramp was closed with an unlocked metal latch. During a continuous observation of the alarmed emergency exit back door on 10/18/24, at 6:40 p.m., the door was opened from 6:40 p.m. to 7:15 p.m.; there was no alarm audible. During a concurrent observation and interview on 12/3/24, at 11:05 a.m., with Certified Nursing Assistant 1 (CNA 1), an alarmed…

    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 · D2024-08-27 · tag F0726 — failed to have competent, trained nursing staff — isolated
    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

    Based on interview and record review, the facility failed to assure nursing staff possessed the competencies and skill sets necessary to provide nursing services to meet the residents' care needs safely for one of one sampled resident (Resident 1), when a Licensed Vocational Nurse(LVN), without an intra-venous(IV-a medical technique that involves administering fluids, medications, or nutrients directly into a vein) and blood withdrawal certificate provided care for Resident 1's peripherally inserted central catheter (PICC- a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein in the chest). This failure had the potential to result in improper infusion of ordered TPN (Total Parenteral Nutrition-a method of feeding that provides nutrients directly into a vein, bypassing the gastrointestinal tract) and cause infection and complications. During a record review of Resident 1's face sheet, printed on 8/27/24, the face sheet indicated Resident 1 was admitted during May 2024, with diagnoses including: surgical aftercare following surgery on 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-25 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure maintenance services to maintain a comfortable, sanitary, and homelike environment when: 1. For Resident 39, room had a missing window covering. 2. For Resident 41, bathroom sink hot water knob was not in good working condition. 3. For Resident 58, room window could not be closed completely. 4. Multiple rooms (Rooms 5, 6, 10, 11,1 2, 16, and 19) had unclean and unpleasant bathroom environments. These failures to ensure a homelike environment had the potential to decrease residents' quality of life, comfort, and well-being. Findings: 1. A review of Resident 39's admission Record printed on 7/24/24, indicated Resident 39 was admitted to the facility on [DATE]. A review of Resident 39's Minimum Data Set (MDS, an assessment tool used to provide care), dated 7/12/24, indicated Resident 39 had a Brief Interview for Mental Status (BIMS, an assessment tool for a resident's orientation to time and capacity to remember. The BIMS score ranges…

    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 · E2024-07-25 · tag F0645 — pattern
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 four (Resident 32, 47, 57 and 67) of five sampled resident's Pre-admission Screening Resident Review (PASRR) was referred to the appropriate state mental authority for evaluation and determination when; 1. Facility did not resubmit a new Level 1 PASRR screening for Residents 32, 47, 67 that remained in the facility longer than 30 days. 2. Facility did not refer Resident 57 for level 2 PASRR evaluation. These failures had the potential to prevent residents from receiving appropriate required mental health services. Findings: 1. Review of Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 5/22/24, indicated Resident 32 was admitted to the facility on [DATE], the Preadmission Screening and Resident Review (PASRR) was coded zero-meaning, Resident 32 was not considered by the State PASRR process to have a serious mental illness. The MDS indicated Resident 32's diagnoses included undifferentiated schizophrenia ( a mental…

    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
Show the remaining 17 citations
  • Potential for harm · E2024-07-25 · tag F0801 — pattern
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility document review, the facility failed to ensure the oversight of food service operations when the facility did not employ a full-time qualified Dietary Services Supervisor, defined as working 35 hours per week, to manage and oversee food operation services for the facility. This failure had the potential to jeopardize the health and well-being of the 92 of 93 residents who received food prepared in the kitchen. Findings: According to the California Code, Health and Safety Code - HSC § 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. During an interview on 7/22/24, at 9:15 a.m., with [NAME] 1 (CK 1), CK 1 stated the Kitchen Manager (KM) was not onsite for the initial kitchen tour, and that the KM only worked part-time. During an interview on 7/24/24, at 1:00 p.m., with KM,…

    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 before2024-07-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served in a safe and sanitary manner when: 1. A ¼ full container of Teriyaki sauce labeled refrigerate after opening was stored in un-refrigerated dry- goods storage 2. A dry food bin marked polenta was ready for use with an expired use-by date, and dry food bins for flour, thickener and grain rice had no use-by dates 3. Two of five cutting boards had deep white scratches 4. A knife rack had sticky brown residue on top 5. An air conditioner unit had thick grey dust on top, and in the air vents 6. The corner of kitchen floor was unclean with food debris buildup These failures placed the residents at risk for food-borne illnesses. Findings: 1. During an initial observation on 7/22/24, at 9:15 a.m., in the kitchen, a ¼ full container of Teriyaki sauce was observed in the dry-storage food pantry, ready for use. On inspection of the back of container, it indicated refrigerate after opening. During an interview on 7/24/24, at 1:00 p.m., with the Kitchen Manager (KM) and the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-25 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide effective pest control for two out of 93 residents. This failure had the potential to result in residents being bothered by roaches. Findings: During an interview on 07/22/24, at 10:18 a.m., Resident 88 stated there was an issue with roaches in her room. Resident 88 stated she noted a roach under her lunch tray several days ago and she notified the MDS Coordinator (MDSC). During an interview on 7/22/24, at 10:49 a.m., MDSC stated that Resident 88 notified her about roaches several days ago and MDSC brought it up in the facility 24 hour meeting and in a group message that included Maintenance Staff (MS) and Environmental Supervisor (ES). During a concurrent observation and interview on 7/22/24, at 11:57 a.m., Resident 55 stated there were roaches in his room, and he had reported them on several occasions to staff members, including to Licensed Vocational Nurse 6 (LVN6). A small live roach, approximately the length of a dime, was observed on the floor in Resident 55's room. During an interview on…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-25 · 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 necessary treatment and care services in accordance with professional standards of practice, comprehensive assessment and care plan for two of two sampled residents (Resident 41 and Resident 85) when: 1. For Resident 41, license nurse (LN) did not assess or offer pain medication before wound dressing change was performed. 2. Resident 85 did not receive pain medication as ordered by the physician. License nurses did not reassess routine use of as needed pain medication. These failures had the potential for Resident 41 and Resident 85 to suffer from unnecessary pain and emotional distress, and to not receive the necessary care and services to ensure effective pain management. Findings: 1. A review of Resident 41's admission Record printed on 7/24/24, indicated Resident 41 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a brain condition that causes a progressive decline in memory, thinking,…

    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 · D2024-07-25 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that two of three sampled residents (Residents 54 and 58) were administered medication to meet their needs. Resident 54 was not given two medications as ordered during an observed medication pass and Resident 58 was not giving prescribed eye drops for two days. These failures had the potential to result in residents' medical conditions worsening. Findings: A review of the admission Record (a document containing the most pertinent information for a resident) for Resident 54, undated, indicated the resident was admitted on 5/2024 with a diagnosis of heart failure. A review of the Physician's Orders for Resident 54, dated July 2024, indicated the resident had orders for Minoxidil 10 milligrams (mg) once daily for hypertension, and Potassium Chloride 20 milliequivalents (mEq) once daily for supplement. A review of the admission Record for Resident 58, undated, indicated Resident 58 was admitted on 10/2023. A review of the Physician's Orders for Resident 58, dated March 2024, indicated Resident 58 had 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-25 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure it maintained a medication error rate of five percent or less. The facility medication error rate was 8.1%, with three errors observed during 37 opportunities. This failure had the potential to result in residents' medical conditions worsening. Findings: During a concurrent observation and interview on 7/24/24, at 9:05 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 was observed passing medication to Resident 54. Resident 54 was noted with an order for potassium chloride (a medication designed to increase a person's potassium). LVN 3 looked through the medication cart and storage area and was unable to locate the potassium chloride. LVN 3 stated the medication was ordered from the pharmacy and had not arrived yet, so LVN 3 was unable to administer the medication to the resident. Continuing the medication pass, LVN 3 prepared two tablets of Vitamin D3 (a medication designed to strengthen bones) 1000 units to administer to Resident 54. LVN 3 then completed the rest of the medication preparation and…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-25 · 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 ensure drugs were stored and disposed of in the proper manner. Three boxes of rectal suppositories were expired, and one emergency medication kit was left open and not replaced. These failures had the potential to result in residents receiving ineffective medication. Findings: During an observation on [DATE], at 1:41 p.m., the medication storage room was observed by two Health Facilities Evaluators (HFEs). During the observation, one emergency medication kit (e-kit) was observed as having been opened. The kit contained controlled substances, insulin, and temperature-sensitive suppositories. Further along the observation, three boxes of Bisacodyl suppositories were observed as having an expiration date of 6/24. This was confirmed with Licensed Vocational Nurse (LVN) 1. The expired medication was placed with the rest of the over-the-counter medications used by the facility. LVN 1 then checked the reorder log for the e-kits, which revealed a…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-25 · 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 interview and record review, the facility failed to ensure clinical records were complete and accurately documented for one of 40 sampled residents (Resident 41) when Resident 41's Hospice Care (a medical care for people focused on palliation [focused on providing relief from pain and other symptoms of a serious illness] of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) Notes were not readily accessible and Hospice Care Visits/Assessments were not accurately documented in resident's electronic medical record. These deficient practices had the potential for Resident 41 to not receive the needed care, services, and treatments due to lack of availability of information to facilitate communication among the Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their patients). Findings: A review of Resident 41's admission Record printed on 7/24/24, indicated Resident 41 was admitted to the facility in 2019. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-04-22 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow proper sanitation, food handling, and food storage practices when: 1. Refrigerator 2 contained the following items: A container which held raw cucumbers, bell peppers and asparagus bunches: the cucumbers and bell peppers were nine days past the use by date on the container label; there was no label for the asparagus. A bag of cilantro leaves with part of the leaves discolored, and no use by date on the bag label. An unlabeled container with a discolored yellow bell pepper. An unlabeled container with a head of wilted cabbage. 2. The freezer had an undated sealed bag of French bread. 3. The freezer section of the freestanding white refrigerator had an undated bag of whipped topping. 4. [NAME] 2 did not perform hand hygiene in between tasks during tray line (serving and plating of food). These failures had the potential to result in food contamination and resident foodborne illnesses. Findings: 1. During a concurrent observation and interview with Registered Dietitian 1 (RD 1) on 4/18/22, at 10:38 a.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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-22 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for one (Resident 133) of 11 sampled residents, the facility failed to develop a baseline care plan within 48 hours of admission. This failure had the potential to result in unmet care needs for Residents 133. Findings: A review of Resident 133's admission Record indicated Resident 133 was admitted to the facility on [DATE] with a diagnosis of cellulitis (inflammation of subcutaneous connective tissue) on lower left and right legs. A review of Resident 133's Order Summary Report Active Orders as of 4/19/22, indicated an order dated 4/4/22: wound consultation with follow-up treatment as indicated. During an interview and concurrent record review on 4/20/22, at 1:33 p.m., with the DON, the care plans for Resident 133 were reviewed. The DON was unable to provide documentation of a baseline or comprehensive care plan to address Resident 133's physician order for wound care and wound consultation. A review of the facility's policy and procedure Comprehensive…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-22 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for one (Resident 45) of 11 sampled residents, the facility failed to develop a comprehensive care plan within seven days of completion of the Minimum Data Set (MDS, a resident assessment tool used to guide care). This failure had the potential to result in unmet care needs for Residents 45. Findings: A review of Resident 45's face sheet indicated Resident 45 was admitted to the facility on [DATE] with multiple diagnosis including obstructive sleep apnea (a blockage of the upper airway occurring during sleep which prevents normal breathing; common causes include swollen tonsils or excessive relaxation of the throat muscles causing collapse/narrowing of the airway). A review of Resident 45's MDS dated [DATE], indicated Resident 45 was able to understand others and be understood. The MDS also indicated Resident 45 was on oxygen therapy. During an interview on 04/19/22, at 10:35 a.m., Resident 45 stated since he had lung surgery a month ago, he had used oxygen…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide weekly showers to one of twenty residents (Resident 27) as requested by Resident 27's emergency contact. This failure resulted in Resident 27's not receiving preferred bathing services (a weekly shower) and had the potential to result in decreased comfort and hygiene. Findings: A review of Resident 27's admission Record (AR), undated, indicated Resident 27 was originally admitted in 2017 with diagnoses of dementia (a chronic disorder marked by memory disorders, personality changes, and impaired reasoning), muscle weakness, and abnormalities of gait and mobility. The admission Record also indicated Resident 27 had a family member as an emergency contact, FAM 1. A review of Resident 27's Minimum Data Set (MDS, an assessment tool used to guide care), dated 1/20/22, indicated Resident 27 was rarely/never able to understand others and rarely/never was understood by others. The MDS indicated it was somewhat important for Resident 27 to choose between shower, tub, bed, or sponge bath. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-22 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, for one of twenty sampled residents (Resident 29), the facility failed to arrange for surgery for treatment of a left eye cataract. (A cataract is a cloudy area in the lens of the eye that leads to a decrease in vision.) The failure to arrange for Resident 29's eye surgery resulted in delayed treatment to improve Resident 29's vision in his left eye for five months and 13 days. Findings: A review of Resident 29's admission Record, undated, indicated Resident 29 was admitted in 2020 with multiple diagnoses including diabetes mellitus (a chronic condition of uncontrolled blood sugar). During a review of Resident 29's care plan, dated 10/27/21, the care plan indicated, The resident has impaired visual function on the left eye. Goal: The resident will show no decline in visual function and . will maintain optimal quality of life . A review of Resident 29's Ophthalmology Consultation Record (OCR), dated 11/3/2021, the OCR indicated Resident 29's vision in the left eye was 20/200 (20/200 means a person with normal vision can stand 200 feet away from…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, for one of eight sampled residents (Resident 74) with limited range of motion (ROM, a joint or body part with limited range of motion, cannot move through its normal range of motion; also known as contractures,), the facility failed to: 1. Apply knee immobilizer (a removable brace to maintain stability of the knee) daily to resident's right (R) knee as ordered by the physician. 2. Provide resident with ROM exercises three times a week as ordered by the physician, and according to the plan of care. These failures resulted in unmet care needs for Resident 74 and had the potential to result in decreased range of motion. Findings: 1. A review of Resident 74's admission Record, dated 4/21/22, indicated Resident 74 was admitted to the facility in February 2022, with diagnoses of Alzheimer's dementia, (a progressive disease that result in memory loss), history of fracture to the right femoral shaft (upper leg bone) and right humerus (upper arm), muscle weakness, and other abnormalities of gait and mobility. A review of Resident 74'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-22 · 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

    Based on observations, interviews, and record reviews, the facility failed to ensure the two alarms on the South Station emergency exit were functional: the emergency exit alarm and the Wanderguard alarm. (Wanderguard is a system to alert caregivers when residents are attempting to exit a facility unsupervised. It is a two-part system: a bracelet worn by the resident, and a sensor installed on an exit. When the bracelet passes across the sensor, there is an audible alarm.) The failure to ensure the audible alarms worked on the South Station emergency exit door resulted in one (Resident 70) of 11 sampled residents entering the patio balcony without authorization or supervision and had the potential for unsafe wandering by other residents. Findings: A review of Resident 70's admission Record indicated she was admitted to the facility in 2017 with a diagnosis of vascular dementia (brain damage due to lack of oxygen to the brain). During a concurrent observation on 4/19/22, at 3:00 p.m., Resident 70 sat in a wheelchair in the South Station non-smoking balcony area and smoked. During a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-22 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow policies and procedures for infection control for one (Resident 133) of 11 sampled residents when Certified Nurse Assistant 1 (CNA 1) entered Resident 133's room without wearing required personal protective equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury). The failure to wear PPE necessary for a resident with contact and droplet precautions (Contact and droplet precautions are actions implemented to prevent the spread of infection based upon the transmission mode of direct or indirect contact with respiratory secretions from the resident or environmental surfaces contaminated with respiratory secretions) had the potential to result in transmission and spread of infection. Findings: A review of Resident 133's admission Record (face sheet) indicated Resident 133 was admitted to the facility on [DATE] with multiple diagnosis including cellulitis (inflammation of…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-22 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolated
    Have policies on smoking.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, for one (Resident 70) of three sampled residents who smoked, the facility failed to ensure smoking policies and procedures were followed when Resident 70 smoked in an area designated as a non-smoking area. The failure to ensure Resident 70 smoked in area with a readily available fire extinguisher, an ashtray made of a noncombustible material, and a metal container with a self-closing cover for emptying ashtrays, had the potential to result in a fire. Findings: A review of Resident 70's admission Record indicated she was admitted to the facility in 2017 with a diagnosis of vascular dementia (brain damage due to lack of oxygen to the brain). During an observation on 4/19/22, at 3:00 p.m., Resident 70 sat in a wheelchair in the South Station non-smoking balcony area and smoked. During a concurrent observation and interview on 4/19/22, at 3:20 p.m., with Resident 70, Resident 70 sat in a wheelchair in her room. Resident 70 stated she had smoked on the South Station balcony patio earlier that day, but she couldn't recall how she had…

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

    Environmental Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to SOL HEALTHCARE — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 52.6+2.4 vs chain
Health inspection 4 of 52.5+1.5 vs chain
Staffing 3 of 53.4-0.4 vs chain
Quality measures 5 of 53.4+1.6 vs chain
The other 7 homes this chain runs (chain average 2.6★, 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 / managerTypeRoleShareSince
SOL HEALTHCARE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST99%since 02/04/2010
MAJER, SOLIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/04/2010
ROCKPORT ADMINISTRATIVE SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/04/2010
DHUGGA, GURPREETIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2019
SINGH, RUBYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/02/2023
ERETZ OAKLAND PROPERTIES LLCOrganizationADP OF THE SNFsince 03/15/2014

CMS files one row per role, so the 11 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$15.9M
Net patient revenuemost recent cost report
+4.0%
Operating marginrevenue minus expenses
$1.9M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 76%Medicare 12%Other / private 11%

About 76% 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 $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$454per resident / day
operating cost
$13,802per month
≈ monthly operating cost
$473per 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 055215. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, 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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