La Paloma Healthcare Center
3232 Thunder Drive, Oceanside, CA 92056 · For profit - Limited Liability company · 93 certified beds · (760) 724-2193 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.2% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.6% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.5% | 1.2% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 7.3% | 7.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.4% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 9.1% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.6% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 82.5% | 98.2% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 2.6% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 9.3% | 10.2% | 21.2% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.1% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 91.7% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.8% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.4% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.76 | 2.25 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.70 | 1.57 | 1.80 | typical |
‡ 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.
60.4% 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 194 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 81.0% 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 84 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 0.63 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 60.4%CMS range 53.6–66.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.2%CMS range 10.3–16.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 81.0% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 76.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 45.2% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 98.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 98.4% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 88.6% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.4%CMS range 2.9–9.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.16 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 93 beds and averages 84.4 residents a day — about 91% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.95 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.37 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.71 hrs/resident/day on weekends vs 4.05 on weekdays — 9% thinner on weekends. RN hours go from 0.45 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2021-07-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fall safety interventions for two of six residents (Resident 35 and Resident 23) reviewed for accidents were provided when: Resident 35's chair/bed silent alarm (an alarm used to help warn staff when a resident is changing position or getting up) was not implemented consistently; In addition, Resident 35's falls were not thoroughly investigated to ensure that all fall preventative measures were implemented. Resident 23's wheechair was placed in an area that was not within the resident's reach. In addition, the facility was not secured during the night when a visitor's entrance was left open and unlocked. As a result, Resident 35 fell eight times while at the facility. One of Resident 35's fall resulted in a laceration on the forehead which required suturing. Resident 23 had the potential to fall and become injured. Furthermore, not securing the facility from potential intruders put the safety of all residents's at risk. Findings:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded for a resident who discharged to the hospital for 1 (Resident #84) of 3 residents reviewed for closed records. Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. An admission Record indicated, the facility admitted Resident #84 on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of multiple sclerosis (an autoimmune disease that affects the central nervous system [brain and spinal cord]), urinary tract infection, and sepsis (a life-threatening medical emergency caused by the body's extreme response to an infection, often leading to organ dysfunction and potentially death). Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, record review, and facility policy review, the facility failed to follow physician orders for 1 (Resident #6) of 2 residents reviewed for skin conditions. Specifically, Resident #6 had an order, dated 03/26/2025, to schedule a dermatology appointment. However, no attempts were made to schedule a dermatology appointment until 04/15/2025. Findings included: A facility policy titled, Physician Orders, revised 06/2013, indicated, Physician orders must be given, managed and carried out in accordance with applicable laws and regulations. A facility policy titled, Resident Appointments, revised 03/2025, indicated, 1. [NAME] Clerk shall coordinate/schedule resident appointments. The policy also stated, 4. [NAME] Clerk will document the appointment in the resident's medical record. An admission Record revealed the facility admitted Resident #6 on 06/11/2022. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson's disease without dyskinesia (involuntary muscle movements), hypertensive heart disease without…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to follow the pharmacist's recommendations for 1 (Resident #6) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Regimen Reviews, revised 05/2019, indicated, The Consultant Pharmacist reviews the medication regimen or each resident at least monthly. The policy revealed the section titled, Policy Interpretation and Implementation included 1. The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. Further review revealed, 8. Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physician for each resident identified as having a non-life threatening medication irregularity. The section further revealed, 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. An admission Record revealed the facility admitted Resident #6 on 06/11/2022.…
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.
- Potential for harm · Dcited before2025-04-17 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to offer the influenza vaccine and provide education regarding influenza immunizations for 1 (Resident #32) of 5 residents reviewed for immunizations. Findings included: A facility policy titled, Influenza Vaccine, revised 08/2016, indicated, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives). The facility policy indicated, 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. The policy indicated, 6. A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in 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.
- Potential for harm · Dcited before2023-08-17 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 interview and record review, the facility failed to honor resident ' s preference for one of three sampled residents (Resident 1) when Resident 1 was showered despite his refusal. This failure had the potential to affect Resident 1 ' s emotional well-being. Findings: A review of Resident 1 ' s admission record indicated he had diagnoses of hemiplegia (weakness to one side of the body), hypertension (elevated blood pressure). A review of Resident 1 ' s minimum data assessment (MDS, an assessment tool) Section C Cognitive Patterns dated 7/19/23 indicated Resident 1 ' s cognition was intact. An interview was conducted on 8/9/23 at 12:31 P.M with Resident 1. Resident 1 stated on 7/31/23 at approximately 7:00 A.M. – 8:00 A.M., certified nursing assistant (CNA) 1 offered him a shower. He (Resident 1) told CNA 1 he did not want to have a shower. Resident 1 instead agreed to a bed bath. Resident 1 was surprised when CNA 1 and a rehabilitation personnel (RP) assisted him up to a shower chair from his bed and was brought to the shower room. A phone interview was conducted with CNA 1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 interview, and record review, the facility failed to provide the needed care for one of three residents (Resident 1) when Resident 1 was not monitored for signs of abnormal blood pressure (BP, pressure of the blood). This failure had the potential to affect the resident ' s well-being. Findings: A review of Resident 1 ' s admission record indicated, he was admitted to the facility on [DATE] with medical diagnoses of congestive heart failure (heart does not pump blood), hypertension (high blood pressure). A review of the prescriber ' s order, dated 6/20/23 indicated, Observe signs and symptoms of bleeding secondary to anticoagulant (medication to prevent blood clots) use. An interview was conducted on 7/6/23 at 12:42 P.M. with licensed nurse (LN 1). LN 1 stated a low BP reading can be a sign of bleeding. LN 1 further stated residents with low BP should be assessed further. A concurrent interview and record review was conducted on 7/6/23 at 1:15 P.M. with the Assistant Director of Nursing (ADON). The ADON…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-07-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 use pressure relieving mattresses as ordered for 4 of 9 residents sampled for pressure related injuries (24, 53, 66, 16). In addition, 1 resident (16) was not repositioned as ordered. As a result, there was the risk of skin breakdown. Findings: 1. Per the facility's Resident Face Sheet, Resident 24 was admitted to the facility on [DATE] with diagnoses to include pressure ulcer (pressure related skin breakdown) of the sacral region (area above the tailbone). Per Resident 24's physician order dated 2/15/21, Treatment: LAL mattress (Low Air Loss mattress, used to relieve pressure). Set mode at alternating, per weight or residents comfort . On 7/7/21 at 8:41 A.M., a concurrent observation and interview was conducted with Resident 24. Resident 24 was lying on an LAL mattress, which was set to 140. Resident 24 stated, she had not asked the facility to adjust the pressure on her mattress. Per Resident 24's clinical record, on 7/5/21 Resident 24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-07-09 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 answer call lights in a timely manner to meet the needs of the residents for 6 out of 10 confidential residents (A, B, C, D, E, and F) and 6 of 22 sampled residents (13, 53, 23, 41, and 71) and 1 unsampled resident (222). This failure had the potential to result in residents not receiving needed services timely and efficiently. Findings: 1. A review of Resident Council Meeting minutes on 5/20/21 and 6/30/21, indicated call lights were not being answered in a timely matter. On 7/7/21 at 10:02 A.M., a group interview with confidential residents was conducted. During the confidential group interview, five out of nine residents raised concerns regarding delay in answering call lights and having insufficient staff to provide care for all the residents. a) Resident A stated call light issues were always ongoing, especially at nighttime. Resident A further stated sometimes when the call light was on, the staff walked by their room without answering the light.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-09 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a policy to prevent abuse for one resident (Resident 2), when the facility did not follow abuse reporting requirements after the resident reported the incident to the staff. This failure had the potential to compromise resident safety. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb (skin infection of the right leg), and speech and language development delay (slower to develop) due to hearing loss on per the facility's Resident Face Sheet. On 7/6/21 at 9:55 A.M., an interview was conducted with Resident 2. Resident 2 stated a nurse threw a creamer packet at him about a month ago around 4:30 A.M. Resident 2 stated he did not know the nurse's name, but the alleged nurse was still working to this date. Resident 2 stated he reported the incident to licensed nurse (LN) 31 and was told she would talk to the alleged staff. Resident 2 stated he had not heard any updates from LN 31.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-09 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an allegation of abuse was reported in a timely manner for one resident (Resident 2). This failure had the potential to compromise Resident 2 and other residents' safety. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb (skin infection of the right leg) and speech and language development delay (slower to develop) due to hearing loss per facility's Resident Face Sheet. On 7/6/21 at 9:55 A.M., an interview was conducted with Resident 2. Resident 2 stated a nurse threw a creamer packet at him about a month ago around 4:30 A.M. Resident 2 stated he did not know the nurse's name, but the alleged nurse was still working to this date. Resident 2 stated he reported the incident to licensed nurse (LN) 31 and was told she would talk to the alleged staff. Resident 2 stated he had not heard any updates from LN 31. On 7/7/21 at 3:13 P.M., an interview was conducted with LN 31. LN 31 stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · D2021-07-09 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 identify and investigate an alleged abuse violation and protect one resident (Resident 2). This failure had the potential to result in physical and emotional harm for Resident 2 and other residents in the facility. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb (skin infection of the right leg) and speech and language development delay (slower to develop) due to hearing loss per facility's Resident Face Sheet. On 7/6/21 at 9:55 A.M., an interview was conducted with Resident 2. Resident 2 stated a nurse threw a creamer packet at him about a month ago around 4:30 A.M. Resident 2 stated he did not know the nurse's name, but the alleged nurse was still working to this date. Resident 2 stated he reported the incident to licensed nurse (LN) 31 and was told she would talk to the alleged staff. Resident 2 stated he had not heard any updates from LN 31. On 7/7/21 at 3:13 P.M., an interview was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-09 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
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 develop safe discharge planning for one of three residents (Resident 2) reviewed for discharge. This failure had the potential to result in Resident 2 being discharged to a facility that may not be able to meet his needs. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses that included cellulitis of right lower limb (skin infection of the right leg) per facility's Resident Face Sheet. Per Resident 2's social service (SS) progress note dated 3/20/21 and 6/18/21, the discharge plan was to go to independent living with Regional Center support. Per Resident 2's SS note dated 7/6/21, Resident 2's niece would take the resident home against medical advice (AMA) either today or tomorrow because the resident had been agitated and trying to leave the facility. Per Resident 2's SS progress note dated 7/7/21 at 2:21 P.M., Resident 2 was appropriate for discharge to group home on 7/7/21 per responsible party (RP) request. Per…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-09 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a physician ordered medication (a laxative -medication to promote bowel movements) was administered to one of three residents (Resident 28) during the medication administration observation. This deficient practice had the potential for Resident 28 to experience constipation (bowel movements that were difficult to pass). Findings: Resident 28 was readmitted to the facility on [DATE], per the facility's Resident Face Sheet. On 7/8/21 at 10:12 A.M., a medication administration observation was conducted with licensed nurse (LN) 21. LN 21 was observed preparing medications for Resident 28. LN 21 prepared Resident 28's polyethylene glycol 3350 (a laxative in powder form) by mixing it into a glass filled with approximately 8 ounces of water. The mixture was colorless and had the appearance of water. A review of Resident 28's physician orders dated 1/8/21, indicated, . (polyethylene glycol 3350) .powder . Special Instructions: to prevent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 interview and record review, the facility failed to ensure the use of as needed psychotropic medication (a medication which effects the mind) was limited to 14 days for 1 of 5 residents sampled for unnecessary medications (Resident 13.) As a result, there was the risk of Resident 13 receiving unnecessary medication. Findings: Per the facility's Resident Face Sheet, Resident 13 was admitted to the facility on [DATE] with diagnoses to include dementia (a mental and physical decline), and anxiety. Per the facility's Prescription Order, on 3/23/21 the physician wrote an order for Resident 13 for a psychotropic medication to treat anxiety. The end date read, Open Ended. Per the Consultant Pharmacist's Recommendation To Inter-Disciplinary Team (IDT) between 6/1/21 and 6/16/21, the Pharmacist wrote, Please evaluate if the order(s) can be discontinued, or document the clinical justification for extending beyond 14 days (and specify the duration beyond 14 days) to keep the facility in compliance with regulations…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-09 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document the decision maker for one of 22 residents (Resident 2) reviewed for medical record accuracy. This failure resulted in confusion among facility's staff and had the potential for delay in medical treatment. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses that included cellulitis of right lower limb (skin infection of the right leg), and speech and language development delay (slower to develop) due to hearing loss per facility's Resident Face Sheet. Per Resident 2's History and Physical (H&P) dated 3/15/21, Resident 2 did not have the capacity to understand and make decisions. Further noted the decision maker was Resident 2's brother. Per Resident 2's Physician's order started on 3/15/21, Resident 2 was capable of understanding rights, responsibilities, and informed consent. On 7/7/21 at 4:15 P.M., an interview with the social service director (SSD) was conducted. The SSD stated Resident 2's niece was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-09 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility's Quality Assurance Performance Improvement (QAPI) committee failed to thoroughly and completely identify and implement areas of their fall prevention program. This resulted in findings of multiple falls for Resident 35, including a fall with injury. See F656, and F689. Findings: During an interview with the facility's administrator (admin) on 7/9/21 at 5:02 P.M., the admin stated the facility started looking at falls last spring. The admin stated the necessary room changes that were required for infection control during the pandemic, required the facility to look at how to best deal with resident falls, since residents could not always be placed near the nursing station. The admin stated they implemented a falling star program, identifying residents whose doors would remain open with frequent visual checks. The admin stated they talked about falls daily at stand up meeting and with the Interdisciplinary Team (IDT). The admin stated they have seen some improvement in the number and trends of falls after adjusting their Performance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure transmission-based precautions (measures used to prevent spread of infection) were appropriately implemented per infection control standards, for 4 of 6 residents (Residents 19, 475, 477, & 478), when: 1. Resident 19 and Resident 475 were placed together in one room while each resident required a different type of transmission-based precautions. 2. Three residents on transmission-based precautions had the doors open. These failures had the potential to increase the risk of infection for other residents and staff in the facility. Findings: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses, which include acute cystitis (bladder infection), malignant neoplasm of prostate (prostate cancer), per the facility's Resident Face Sheet. According to Resident 19's progress notes, dated 6/30/21, the resident received antibiotics due to a Methicillin-resistant Staphylococcus aureus (MRSA- a bacteria resistant to some common…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-04-26 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure 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 provide evidence of nursing staff competencies (evidence the nursing staff had the knowledge and skills required for their role) for three of three LNs (1, 2, and 3). As a result, there was the potential for resident care to be compromised due to the lack of knowledge and skills of the nursing staff. Findings: On 4/24/19 at 4:30 P.M., an interview was conducted with LN 1. LN 1 was unable to demonstrate he had the knowledge to care for a resident returning from dialysis. On 4/25/19 at 3:37 P.M., an interview was conducted with LN 2. LN 2 was unaware of her responsibilities for the care of a resident returning from dialysis. According to LN 1's employee file, LN 1 was hired on 10/10/17. Per the New Employee Orientation Checklist, the box for LN Skills Checklist was blank. There was no evidence of nursing competencies within LN 1's employee file. According to LN 2's employee file, LN 2 was hired on 5/17/16. Per the New Employee Orientation Checklist, the box for LN Skills Checklist was blank. There was no evidence of 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.
- Potential for harm · E2019-04-26 · tag F0801 — patternEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dietetic services staff observation, interviews, and document reviews the facility failed to ensure safe and effective Dietetic Services oversight in accordance with the facility contract. Failure to ensure effective oversight of day to day dietetic services operations could place 88 residents at nutritional risk, and in turn, further compromise their medical status. Findings: During the annual recertification survey from 4/23/19-4/26/19, multiple issues pertaining to dietetic services were unmet and identified in relation to: 1. the evaluation of dietary staff competency (cross reference F802), 2. the oversight and delivery of sanitation, food safety, and food storage in the kitchen (cross reference F802, 803, 812), and; 3. the overall evaluation of food production in relation to therapeutic diets and menu compliance (cross reference F803). 1. On 4/23/19 at 7:52 A.M., during the initial kitchen tour, an observation and interview was conducted with DSW 1 and DSS. DSW 1 incorrectly demonstrated 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.
- Potential for harm · E2019-04-26 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the 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 ensure: 1. The pureed (food blended to the consistency of applesauce or milkshake thick liquid) diet recipe was followed for nine residents; 2. The fortified diet was followed for 22 residents; and, 3. The therapeutic menu was followed for a renal diet. These failures had the potential to provide meals that did not meet the nutritional needs of residents who received puree, fortified, and renal diets and further compromise their health status. Cross reference 801 Findings: 1. On 4/23/19 at 11:31 A.M., an interview was conducted with CK 1, during lunch tray preparation. CK 1 stated the lunch entree being served was beef stew and corn bread. CK 1 stated she prepared 10 pureed servings for the entrée by using a pureed meat recipe and not the recipe for [NAME] Beef Stew. CK 1 stated instant mashed potatoes flakes and gravy were used as a thickener in the pureed meal preparation. On 4/23/19 at 11:33 A.M., an interview was conducted with 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.
- Potential for harm · E2019-04-26 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure sanitary conditions were maintained during food storage when: 1. Two of 14 onions which had black discoloration were not discarded; 2. Two of seven dried cereal bowls were not discarded 24 hours after being prepared and one was not discarded 48 hours after being prepared; 3. Three serving scoops were dirty with green and brown crusted substances and were stored with clean serving utensils; 4. Sixteen plastic bowls were stored wet underneath a food prep counter; and, 5. Three light bulb panels directly above the food preparation area and tray line station were exposed and uncovered. These failures had the potential to cause widespread food borne illness among residents who consume food from the kitchen. Cross reference 801 Findings: 1. On 4/23/19 at 10:51 A.M., an observation and interview was conducted with the DSS inside the walk-in refrigerator. On a shelf in the back of the refrigerator, there was a large clear rubber bin containing approximately 14 onions. Two onions inside the bin contained a dark…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-04-26 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (4) was assisted with feeding in a respectful manner. This failure had the potential to negatively impact Resident 4's self-esteem. Findings: Resident 4 was admitted to the facility on [DATE] with diagnoses, which included heart failure and palliative (comfort) care, per the facility's Resident Face Sheet. On 4/24/19 at 7:46 A.M., Resident 4 was observed sitting up in bed with a breakfast tray in front of her. Standing on the left side of the bed, was a staff member feeding the resident with a fork. The staff member was standing over Resident 4, approximately two feet higher than the resident's head and they were not positioned at eye level. On 4/24/19 at 7:48 A.M., an interview was conducted with CNA 23. CNA 23 stated she should not have been standing over Resident 4 while feeding her. CNA 23 stated she needed to be at eye level with the resident and she should have been sitting next to the resident,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-26 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the use of a hearing aid for one of three residents (66) with impaired hearing. As a result, there was a potential for Resident 66 to experience decreased socialization and isolation. Findings: Resident 66 was admitted to the facility on [DATE], with chronic obstructive pulmonary disease (a lung disease that affects gas exchange), per the facility's Resident Face Sheet. On 4/23/19 at 2:29 P.M., during the initial tour of the facility, an interview was conducted with LN 21. LN 21 stated Resident 66 was hard of hearing in her right ear. LN 21 stated staff had to speak loudly on Resident 66's left side, to be heard. LN 21 stated the facility was waiting to get hearing aids for the resident. According to Resident 66's quarterly MDS, dated [DATE], Section B, 0200 titled Hearing, was coded as a 1 to indicate Resident 66 had minimal difficulty hearing. According to Resident 66's care plan, dated 4/11/19, titled Communication, .Right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-04-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 accurately assess the skin for one of 18 sampled residents (42). In addition, Resident 42's care plan was not revised when the resident's skin was reassessed by the physician and the skin issue was resolved. This inaccurate skin assessment and failure to revise the resident's care plan had the potential for confusion and miscommunication among staff and affect Resident 42's care. Findings: Resident 42 was admitted to the facility on [DATE] with diagnoses, which included colostomy (a surgical procedure that brings the large intestine out via the abdomen for bowel waste), and obstructive reflux uropathy (instead of flowing into the bladder the urine flows back to the kidneys), per the facility's Resident Face Sheet. This document also indicated Resident 42 was her own responsible party. During an interview with Resident 42 on 4/23/19 at 9:13 A.M., the resident stated she had a surgical wound on her abdomen that had been slow to heal, and she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-04-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide proper supervision during a shower for one of 18 sampled residents (41). This failure resulted in Resident 41 falling from a shower chair and hitting his head. Findings: Resident 41 was admitted to the facility on [DATE] with diagnoses, which included dementia (a loss of mental abilities that leads to impairments in memory, reasoning, planning, and behavior), per the facility's Resident Face Sheet. According to Resident 41's MDS assessment, dated 2/28/19, the resident's cognitive skills were severely impaired. This assessment also indicated Resident 41 was totally dependent with bathing, requiring two-person assistance. On 4/23/19 at 8:55 A.M., Resident 41 was observed lying on his right side in bed. The resident's bed was in the lowest position. During an interview with Resident 41's family member (FM) on 4/23/19 at 9:09 A.M., the FM stated the resident fell while in the shower a few months ago. Resident 41's FM stated she heard 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.
- Potential for harm · D2019-04-26 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 administer a PRN (as needed) medication for constipation per the physician's order for one of two residents (4), reviewed for constipation. As a result, Resident 4 experienced abdominal discomfort and an episode of fecal impaction (hardened stool stuck in the rectum) one month prior. This failure also had the potential to cause a bowel obstruction (a blockage of the intestines). Findings: Resident 4 was admitted to the facility on [DATE], with diagnoses which included heart failure and palliative (comfort) care, per the facility's Resident Face Sheet. According to Resident 4's progress notes, dated 3/13/19 at 10:34 P.M., .tried to manually disimpact (removal of feces) pt (patient) as ordered .one, small hard marble-like stool. Noted w/ (with) high impaction. Pt given soap suds enema at this time . According to Resident 4's physician orders, dated 10/8/18, an order for magnesium hydroxide (an oral laxative - a medication to stimulate 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.
- Potential for harm · D2019-04-26 · tag F0802 — failed to prepare enough nourishing food — isolatedProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff for the food and nutrition services department competently carried out kitchen duties in a safe, and sanitary manner when: 1. A staff member was unable to verbalize and demonstrate correct techniques related to testing sanitizer buckets; and 2. A staff member was unable to demonstrate the correct technique for testing the sanitation level on the dishwasher. These practices had the potential for residents to be exposed to food borne illness, due to lack of staff training and monitoring of their duties. Cross reference 801 Findings: 1. On 4/23/19 at 7:50 A.M., an observation and interview was conducted with DSW. DSW demonstrated the testing of a sanitizing solution inside a red bucket. DSW dipped the test strip in the bucket solution for approximately 1-2 seconds. The test strip turned green which indicated the sanitizer solution was at the appropriate level. DSW stated if the test strip turned green, it indicated the sanitizing solution was dirty and it needed to be changed. DSW stated the strip…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-26 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary practices were implemented for resident's food brought in from the outside. Failure to ensure safe food storage and reheating procedures for residents' food brought in from the outside had the potential to result in foodborne illness. Cross reference 801 Findings: On 4/23/19 at 3:14 P.M., an interview was conducted with CNA 20. CNA 20 stated resident food brought in from the outside was stored in the nurse's station refrigerator for a certain amount of days, but she did not know how many days. CNA 20 stated the facility could not store resident fast food overnight in the refrigerator. On 4/24/19 at 8:55 A.M., an interview was conducted with LN 23. LN 23 stated resident food from the outside was, Good for 48 hours and stored in the refrigerator inside the med room. LN 23 further stated the LNs checked the food before it was given to residents and she did not know about reheating procedures. On 4/24/19 at 9:32 A.M., an interview was conducted with CNA 21. CNA 21 stated resident food was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-04-26 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 administer a vaccine in a timely manner for one of 10 sampled residents (74). As a result, Resident 74 was not vaccinated for influenza (flu) during influenza season, and had the potential to contract and spread influenza. Findings: Per the facility's Resident Face Sheet, Resident 74 was admitted to the facility on [DATE] with diagnoses to include, altered mental status and dementia (cognitive decline). On 4/24/19 at 3:03 P.M., a concurrent interview and record review was conducted with the DSD. The DSD was unable to find documentation to indicate the facility administered an influenza vaccine to Resident 74. On 4/24/19 at 3:29 P.M., an interview was conducted with the DSDA. The DSDA stated, the facility was still giving influenza vaccines through the end of April 2019 per the CDC recommendation. According to Resident 74's Consents - Informed Consent - Influenza Vaccine form, the form was signed by Resident 74's responsible party (person who made…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to PACS GROUP — 274 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.9 | +2.1 vs chain |
| Health inspection | 5 of 5 | 2.5 | +2.5 vs chain |
| Staffing | 3 of 5 | 2.5 | +0.5 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| NOVAK, LOREN | Individual | CONTRACTED MANAGING EMPLOYEE | since 09/01/2021 |
| DUERDEN, JONATHAN | Individual | W-2 MANAGING EMPLOYEE | since 10/02/2023 |
| APT, FREDERICK | Individual | CORPORATE OFFICER | since 01/01/2024 |
| HANCOCK, MARK | Individual | CORPORATE OFFICER | since 01/01/2024 |
| JERGENSEN, JOSHUA | Individual | CORPORATE OFFICER | since 01/01/2024 |
| MITCHELL, JOHN | Individual | CORPORATE OFFICER | since 01/01/2024 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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.
This home reported $883K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055335. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, 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.