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St Paul's Towers

100 Bay Place, Oakland, CA 94610 · Non profit - Corporation · 43 certified beds · (510) 835-4700 Medicare only — no Medicaid

Call the home — (510) 835-4700 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
  • 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 (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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) 5 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
180 Grand Ave · (510) 208-4700 · Call to confirm hours
Pharmacy
2650 Broadway · (510) 879-1013 · Call to confirm hours
Grocery
230 Bay Pl · (510) 834-9800 · Call to confirm hours
Park
Lake Merrit In Oakland Ca · Typically dawn to dusk
Place of worship
114 Montecito Ave · (510) 834-4314

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

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.9%10.2%15.4%better
Long-stay residents who lose too much weight9.8%4.0%5.4%worse
Long-stay residents with a catheter left in their bladder1.0%0.8%0.9%typical
Long-stay residents with a urinary tract infection1.5%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened3.3%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication0.0%13.7%18.9%check this — see note marked star below the table
Long-stay residents with pressure ulcers7.8%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control22.8%10.2%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table7.5%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 vaccine98.6%93.2%79.4%better
Short-stay residents rehospitalized after admission32.2%23.0%22.6%worse
Short-stay residents with an outpatient ER visit21.6%11.2%12.0%worse

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

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

62.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 110 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.9%U.S. median 51.5%
Got home and stayed home
9.3%U.S. median 10.7%
Went back to hospital
69.1%U.S. median 56.6%
Met the expected recovery
0.59U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.33hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 69.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 68 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 0.59 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.9%CMS range 54.8–72.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.3%CMS range 7.1–13.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge69.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge47.1%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 discharge57.4%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 identified98.9%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 setting91.3%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 4.4–13.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 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

1.07
RN hours/ resident / day
0.65
LPN hours/ resident / day
2.51
Aide hours/ resident / day
4.22
Total nurse hours/ resident / day
0.70
RN hoursweekends
23.3%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 43 beds and averages 29.7 residents a day — about 69% occupied, or roughly 13 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.22 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.07 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.51 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 3.57 hrs/resident/day on weekends vs 4.49 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.22 to 0.70 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 23% is below the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2024-09-12)
9
at the previous standard inspection (2022-10-13)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

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

  • Potential for harm · Fcited before2024-09-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. A braising pan, a rolling pin, three storage bins, a citrus juicer, a kitchen drawer, and a juice dispenser machine had black particles/residue or chipped paint, 2. Nine balsamic dressing containers, cut lettuce, cut tomatoes, mayonnaise, bag of bread, mozzarella cheese, burrata cheese, and a bag of prosciutto had no use-by date or had beyond use-by-dates, 3. Three compartment sink's pipe had a leak and a toilet plunger was stored under the three-compartment sink (a sink with three compartments that allows kitchen staff to wash, rinse, and sanitize dishes), and 4. Gloves used to wash dishes in the three-compartment sink were stored on top of the left corner of the three-compartment sink wastewater tank (a wastewater tank stores and treats wastewater from the sink in the tank before releasing the wastewater to the environment). These failures had the potential for contamination of food resulting in food borne illness for…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-09-12 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when the dumpsters were not closed and a laundry bin was used as garbage receptacle. This failure had the potential of harborage and feeding of pest. Findings: During an observation on 9/9/24 at 11:10 a.m., with Environmental Services Manager (ESM), three dumpsters located by the side of the facility were full of trash bags and were not closed or covered. A laundry bin designated for use of the residents' soiled laundry was filled with bags of trash. During an interview on 9/09/24 at 10:53 a.m., with ESM, ESM stated the dumpsters should be covered. ESM stated the laundry bin for soiled laundry should not be used as a garbage receptacle. During an interview on 9/10/24 at 1:37 p.m., with Registered Dietician (RD), RD stated the garbage dumpsters' lids should be closed to prevent pests and rodents' infestation. During a review of the facility's policy and procedure (P&P) titled, Food-Nutrition Services, revised August 2022, the P&P indicated, . The SNF (skilled nursing…

    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 · D2024-09-12 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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

    Based on observation, interview and record review, the facility failed to ensure standards of professional practice were maintained during medication administration for one of two sampled residents (Resident 80) when licensed nurse left Resident 80's Oxycontin tablet (a controlled substance used to treat moderate to severe pain) on top of the medication cart unattended. This failure had a potential for unauthorized access to the medication that could lead to harm or drug diversion (occurs when a medication is taken for use by someone other than whom it is prescribed). Findings: During a record review of Resident 80's admission Record (AR) dated 9/12/24, the AR indicated Resident 80 had multiple diagnoses including intervertebral disc disorder of lumbar region (a disease that can cause low back pain) and scoliosis of lumbar region (a condition that caused by abnormal side-ways curve of the spine in the lower back causing pain and discomfort). During a record review of Resident 80's Medication Administration Record (MAR) dated 9/1/24 to 9/30/24, the MAR indicated Resident 80 had 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-12 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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 ensure one of two sampled residents (Resident 82) was free from unnecessary drug when Resident 82's PRN (pro re nata [a Latin phrase], meaning as needed, or as necessary) order for Oxycodone-Acetaminophen (a controlled substance used to help relieve moderate to severe pain) had no clear indications when to give one tablet versus two tablets. This failure had the potential to result in unnecessary use of Oxycodone-Acetaminophen medication without proper indication, placing Resident 82 at risk for adverse side effects and health safety issues. Findings: During a record review of Resident 82's Medication Administration Record (MAR), dated 8/1/24 to 8/31/24 and 9/1/24 to 9/30/24, the MAR indicated Resident 82 had an order of Oxycodone-Acetaminophen Oral Tablet 5-325 milligrams/mg (Oxycodone with Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain take one tab to two tabs for pain with start date of 8/18/24. During a record review of Consultant Pharmacist's (CP) Medication Regimen Review (MRR, includes review…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 two sampled residents (Resident 10) was free from unnecessary psychotropic drugs (medications that are capable of affecting the mind, emotions, and behavior) when Resident 10's PRN (pro re nata [a Latin phrase], meaning as needed, or as necessary) order for Temazepam (used on a short-term basis to treat difficulty falling asleep or staying asleep) had no end date and rationale for continued use beyond 14 days. This failure had the potential to result in unnecessary prolonged use of a psychotropic medication, placing Resident 10 at risk for adverse side effects and health safety issues. Findings: During a record review of Resident 10's Order Summary Report (OSR), dated 5/20/24, OSR indicated, Temazepam Oral Capsule 15 milligrams (mg) . Give 1 capsule by mouth every 24 hours as needed for insomnia related to primary insomnia The OSR further indicated, Communication Method - Prescriber Written, with Order Status that indicated Active, and Start Date of 5/15/24. The OSR End Date was blank. During a record review…

    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 · Ecited before2022-10-13 · 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, interviews and record review, the facility failed to follow proper sanitation and food storage practices when: - The High temperature dishwasher was not within the required temperature range - Kitchen floor tiles had brownish residual discoloration - Juice dispenser had a brownish substance around the nozzle - Food prep refrigerator had brownish debris at the bottom shelf area. - One 5 LB (pound) can of creamy peanut butter was past the used-by-date 9/22/22 - Food steamer with brownish substance and crumbs at the bottom shelf area. These deficient practices had the potential to result in foodborne illness and did not ensure sanitary conditions. Findings: During the initial observation tour of the kitchen on 10/10/22 at 9:36 a.m., accompanied by the Director of Dietary Services (DDS) and Registered Dietician (RD), showed the following: Kitchen floor tiles had brownish black residual discoloration, Juice dispenser with brownish substance around the nozzle, prep Refrigerator had brownish debris at the bottom shelf area, one can of creamy peanut butter was past 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 · D2022-10-13 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 two sampled residents (Resident 18 and Resident 23) who were unable to carry out activities of daily living, the facility failed to provide foot care and treatment as follows. 1. Resident 23's toenails were long and had jagged edges. This failure had the potential for toenail trauma and foot complications related to diabetes (blood sugar disorder). 2. Resident 18 did not receive podiatry services (services provided by a foot specialist doctor) for the resident's long, thick, and yellowish toenails as ordered by the physician. This failure had the potential for toenail trauma. Findings: 1. Review of Resident 23's admission Record indicated Resident 23 was admitted to the facility on [DATE] with diagnoses that included diabetes, dementia (memory and decision-making capacity is impaired affecting ADLs) and need for assistance with personal care. During an observation on 10/10/22 at 10:50 a.m., Resident 23 had long toenails and some toenails had jagged…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for one of one (Resident 76) investigated for accident hazards, the facility failed to ensure Resident 76's environment was free from accident hazards when personal belongings were not within reach. This failure had the potential to result in another fall episode. Findings: Review of Resident 76's admission record indicated Resident 76 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis (narrowing of the spinal canal resulting in pain, numbness, and muscle weakness) and osteoporosis (bone disease that leads to decrease in bone strength and increases the risk of fractures). Review of Resident 76's Baseline Care Plan with Summary dated 10/6/22 indicated Resident 76 was alert and oriented, able to understand, and communicated easily with staff. Review of Resident 76's fall risk assessment dated [DATE] indicated Resident 76 was identified as having a moderate risk of falling. Review of Resident 76's IDT (Interdisciplinary…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-13 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to have a Registered Nurse (RN) coverage for at least 8 consecutive hours a day on 10/2/22, 10/8/22, and 10/9/22. This deficient practice had the potential to cause delayed delivery of necessary assessment and treatment services for residents day-to-day care. Findings: Review of the nursing staffing assignment and sign-in sheet dated 10/3/22, 10/8/22 and 10/9/22 indicated facility did not use the services of an RN for at least 8 consecutive hours a day. During an interview and record review of the October staffing schedule on 10/11/22 at 10:59 a.m., the Director of Nursing (DON) stated there are some days the facility did not have an RN coverage for at least 8 consecutive hours a day on weekends. DON stated the facility had tried to recruit RNs, but did not have RN coverage on 10/2/22, 10/8/22, and 10/9/22. The Facility Assessment Tool updated 9/13/22 indicated, the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.…

    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 · Dcited before2022-10-13 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, for one of five residents (Resident 78) observed for medication pass administration, the facility failed to provide pharmaceutical services when calcium-citrate-magnesium tablets were not available for medication administration. This failure had the potential to result in low blood calcium levels for Resident 78. Findings: Review of Resident 78's Order Summary Report for October 2022 indicated an order for calcium citrate-magnesium-mineral tablet one tablet by mouth one time a day. During an observation and concurrent interview with the Licensed Vocational Nurse 2 (LVN 2) on 10/11/22 at 9:30 a.m., LVN 2 did not administer calcium citrate-magnesium-mineral tablet to Resident 78. LVN 2 stated the medication order would have to be clarified with the Attending Physician (AP) because the way it was written was confusing. LVN 2 pulled out all the drawers in the medication cart and could not show a bottle of calcium citrate. During an interview and concurrent review of Resident 78's Medication Administration Record (MAR) for October 2022…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · Dcited before2022-10-13 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility did not follow their policy and procedure for Medication Regimen Review (MRR) and failed to act upon the Consultant Pharmacist's (CP) report of the medication irregularities for two (Resident 20 and 75) sampled residents when; 1. Resident 20, had CP recommendations to taper and decrease or discontinue use of Metformin ER (extended release medication to treat diabetes, a blood sugar disorder), Jardiance (diabetes), Effexor ER, Wellbutrin (antidepressant) and Pramipexole (treats symptoms of Parkinson's disease, a disorder of the central nervous system that affects movement, tremors) did not include the physician's medical/clinical rationale for continuing or disagreeing with the MRR recommendations. 2. For Resident 75, the CP recommendation was not acted upon in a timely manner. This deficient practices had the potential for residents to receive unnecessary drugs and result in adverse effects. Findings: 1. Review of order summary report dated 9/12/22 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to ensure two sampled residents (Resident 13 and 20) were free from unnecessary drugs when; -Resident 13 was administered Olanzapine (Zyprexa-an antipsychotic) medication without appropriate indication for use. -Resident 20 was administered Rexulti and Bupropion HCL ER (antidepressants) without adequate monitoring of behavior manifestations. {Psychotropic drug is any drug that affects brain activities associated with mental processes and behavior} {According to the manufacturer, Zyprexa is not approved for use in older adult with dementia-related psychosis}. [Reference: https://www.drugs.com/pro/zyprexa.html]. This deficient practice had the potential for residents to receive unnecessary medications and adverse side effects. Findings: Review of Resident 13's order summary dated 8/19/22 indicated the physician prescribed Zyprexa 5 mg (milligram) give 0.5 mg tablet by mouth at bedtime for prevention of psychosis (thoughts and emotions are impaired so that contact is lost with external reality). During an interview on 10/12/22…

    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 · D2022-10-13 · 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 the medication error rate did not exceed five percent (%) or greater when three medication errors were observed out of 25 opportunities for error that totaled 12%. The medication error rate was calculated as follows: three divided by 25, then multiplied by 100, which equaled 12%. 1. a. For Resident 75, the Licensed Vocational Nurse (LVN) 5 did not give instructions on how to use Spiriva (an inhaler medication to treat asthma [a condition when a person's airways become inflamed, narrow and swell which makes it difficult to breathe]) prior to handing the medication to Resident 75 for administration. b. For Resident 75, LVN 5 administered three inhalation medications in an incorrect sequence when Spiriva and Symbicort (a corticosteroid inhalation medication) were administered before albuterol-ipratropium nebulizer (combination of bronchodilators, works by relaxing and opening the air passages to the lungs to make breathing easier) treatment. These failures had the potential to result in Resident 75 not…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-13 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure proper garbage and refuse disposal when bags of garbage were stored in a dumpster without lids outside the kitchen area. This failure had the potential for foul odors and attract unwanted pests. Findings: During an observation on 10/11/22 at 8:50 a.m., in the presence of the Director of Dietary Services (DDS), bags of garbage were stored in an open dumpster that did not have lids located at the back of the kitchen area. The dumpster was full with garbage. During an interview on 10/11/22 at 8:50 a.m., DDS stated the dumpster had no cover. DDS said the garbage is removed on Mondays, Wednesday and Fridays. According to the United States Food and Drug Administration (FDA) Food Code 2017, under Outside Receptacles, receptacles and waste handling units for refuse with materials containing food residue and used outside the food establishment shall be designed to have tight-fitting lids or covers.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-06-27 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the policy and procedure and act upon the pharmacist's identified medication irregularities on the Medication Regimen Review (MRR) report for three (Residents 1, 6, 26) of 15 sampled residents as follows: 1. For Resident 1, the monitoring of digoxin (heart medication) to ensure maximal efficacy and minimal risk for digoxin toxicity. 2. For Resident 26, the monitoring of serum blood levels of potassium and magnesium related to digoxin therapy, including the blood pressure (BP) hold (do not give) parameters ordered by the physician which was not implemented. 3. For Resident 6, the admission Regimen Review and Monthly Drug Regimen Review for use of the antipsychotic medication, Seroquel (treats symptoms of hallucinations, delusions, severe depression .) was not followed up for the medical indication and justification for its use. These failures had the potential to result in adverse effects and not achieving optimal health when staff…

    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 · E2019-06-27 · tag F0790 — failed to provide dental care — pattern
    Provide routine and 24-hour emergency dental care for each resident.
    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 assist and provide one (Resident 22) of 15 sampled residents with dental services in a timely manner. This failure resulted in Resident 22's denture discomfort, the inability to eat preferred foods, and weight loss. Findings: The record review of the admission Records indicated Resident 22, an elderly frail resident was admitted on [DATE] with multiple diagnoses including, unspecified dementia without behavioral disturbance (a person loses the ability to think, remember, learn, make decisions, and solve problems), dysphagia (difficulty swallowing foods or liquids), and major depressive disorder. In an observation and concurrent interview in Resident 22's room on 6/25/19 at 9:48 a.m., Resident 22 opened her mouth and complained that her upper dentures were not fitting properly and it hurts when she eats. A record review of the Weight and Vitals Summary record reflected Resident 22 weighed 123.4 pounds (lbs) on admission. Further review…

    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 before2019-06-27 · 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 prepared and stored in a sanitary manner when: 1. Inside the walk-in refrigerator # 1 and # 2, there were multiple food items that were stored beyond their use-by date. 2. The walk-in (#3) freezer had a frosty interior with build-up of formed ice from the ground and up to the ceiling. Multiple boxes inside the freezer were also frosty that included 11 containers of beef broth. A container of multiple packages of beef liver was on the freezer floor. 3. A dietary staff entered the kitchen and walked back and forth near the trayline without wearing a hair cover. 4. The ice machine in the kitchen was not sanitized according to the manufacturer's instructions. These failures had the potential to result in food borne illnesses. Findings: 1. During an initial kitchen observation and concurrent interview with Registered Dietician (RD) on 6/25/19 at 8:48 a.m., the walk-in refrigerator #1 had the following: - An opened container of black beans prepared 6/19/19 had a use-by date 6/23/19. - Three packages…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-27 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan for three (Residents 1, 6, 22) of 15 sampled residents when staff did not develop a plan of care for Resident 1's Chronic Congestive Heart Failure [CHF -heart does not pump blood adequately] and monitor for digoxin (heart medication) toxicity, Resident 22's dental issues and concerns that could effect the nutritional intake, and monitor Resident 6's Seroquel (antipsychotic medication used to treat hallucinations, delusions, severe depression .) for potential side effects. These failures had the potential for Residents 1, 6, and 22 to not receive individualized care based on their medical and nursing assessments and planned accordingly to meet the residents' care needs. Findings: 1. A record review of the admission Records indicated that Resident 1 was admitted on [DATE] with multiple diagnosis including, CHF, chronic atrial fibrillation (an irregular heart beat that causes the top chambers of your heart to quiver) 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 · Dcited before2019-06-27 · 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 medication and biologicals were current and safe for use on residents when one bottle of Aspirin (medication used for pain, inflammation or blood thinning), and two bottles of glucometer (a blood glucose monitoring device) control solutions were expired. This failure had the potential to put the residents at risk for receiving medication that was not effective beyond their expiration dates, and inaccurate test results from using expired glucometer control solutions. Findings: During the medication room inspection on 6/26/19 at 8 a.m., an unopened bottle of Aspirin (ASA) 325 milligrams (mg) containing 100 tablets and expiration date of February 2019 was observed in the cabinet stored with currently used over-the-counter (OTC) medications. In an interview with the Licensed Vocational Nurse (LVN 1) on 6/26/19 at 8 a.m., LVN 1 stated the expired bottle of ASA should not be stored with the currently used medications, and the expired bottles will be discarded. During a Medication Cart (MC 2) inspection 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-06-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 of 12 sampled residents (Resident 6), the facility failed to ensure that Resident 6 was given antipsychotic (medication that treats psychosis) medication for a specific documented condition when Resident 6 was given Seroquel (an antipsychotic) without an identified target behavior. This failure had the potential to result in the unnecessary continued use of antipsychotic medication without a clear medical indication for its use and had the potential for adverse side effects. Findings: A record review of Resident 6's admission Record indicated Resident 6 was re-admitted to the facility on [DATE] with multiple diagnoses that included dementia (condition where memory and decision making skills is impaired affecting daily life function) without behavioral disturbance. The record review of Resident 6's Order Summary Report dated 6/26/19 indicated an order dated 3/17/16 for Resident 6 to receive Seroquel 25 milligram (mg), one half tablet by mouth at bedtime…

    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

“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 FRONT PORCH — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 54.8+0.2 vs chain
Health inspection 4 of 54.2-0.2 vs chain
Staffing 5 of 54.9≈ chain avg
Quality measures 5 of 54.8+0.2 vs chain
The other 8 homes this chain runs (chain average 4.8★, 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
FRONT PORCH COMMUNITIES AND SERVICESOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 04/01/2022
DURANTEAU, NANCYIndividualCORPORATE DIRECTORsince 04/01/2021
FORTE, VINCENTIndividualCORPORATE DIRECTORsince 04/01/2021
HANDY, JOANNEIndividualCORPORATE DIRECTORsince 04/01/2022
JACOBS, LAURAIndividualCORPORATE DIRECTORsince 01/01/2019
KROEKER, KEVINIndividualCORPORATE DIRECTORsince 01/01/2018
MCGOVERN, MARIONIndividualCORPORATE DIRECTORsince 01/01/2017
SPENCER, PETERIndividualCORPORATE DIRECTORsince 01/01/2026
TONNU, DIEMLANIndividualCORPORATE DIRECTORsince 01/01/2018
WESSON, OLIVERIndividualCORPORATE DIRECTORsince 01/01/2017
WHITTAKER, SUSANIndividualCORPORATE DIRECTORsince 01/23/2018
KELLY, SEANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 03/06/2023
SALVADOR, EDUARDOIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
VRANICH, RACHELIndividualCORPORATE OFFICERsince 06/17/2022
AKOPYAN, GEVORKIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/12/2022
ICHIEN, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/27/2026
KISAJJA, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/28/2021
MACANGO, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/04/2026
MARCELO, CHERRYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/19/2025
MCCARRON, KATHLEENIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/24/2026
MCMULLIN, MARYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
OLSON, KARIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
SAIRAM, SAMIRIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2018
MERKIN, NICKOLASIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 10/10/2025
NELSON, HARRYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 09/30/2025
PENNINGTON, PAIGEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 09/30/2025

CMS files one row per role, so the 31 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$6.0M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
$328K
Related-party expense1% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 18%Other / private 82%

This home reported $328K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$2,398per resident / day
operating cost
$72,912per month
≈ monthly operating cost
$486per 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

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the California Medicaid page for homes that do.

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 055156. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-12, 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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