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Canterbury Woods

651 Sinex Avenue, Pacific Grove, CA 93950 · Non profit - Corporation · 24 certified beds · (831) 373-3111 Medicare only — no Medicaid

Call the home — (831) 373-3111 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 (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (19% 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
700 Cass St · (831) 641-0977 · Call to confirm hours
Pharmacy
510 Lighthouse Ave Ste 7b · (831) 373-7712 · Call to confirm hours
Grocery
242 Forest Ave · (831) 375-9581 · Call to confirm hours
Park
Caterpillar Park · Typically dawn to dusk
Place of worship
724 Forest Ave · (831) 917-3969

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
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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents with a urinary tract infection0.0%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 with pressure ulcers2.9%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control20.9%10.2%21.2%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine97.8%93.2%79.4%better
Short-stay residents rehospitalized after admission31.7%23.0%22.6%worse
Short-stay residents with an outpatient ER visit10.0%11.2%12.0%better

* 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.

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.

62.0% 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 151 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.0%U.S. median 51.5%
Got home and stayed home
9.0%U.S. median 10.7%
Went back to hospital
65.3%U.S. median 56.6%
Met the expected recovery
0.97U.S. median 0.31
Therapy hours / resident / day
0.40hours / resident / day
Physical therapy
0.55hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 65.3% 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 95 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 0.97 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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 SNF62.0%CMS range 53.1–69.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.0%CMS range 6.1–12.710.7%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 discharge65.3%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 discharge63.2%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 discharge61.0%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 identified98.6%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 setting97.1%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 worsened1.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.7%CMS range 3.5–11.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.821.02Oct 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

1.46
RN hours/ resident / day
1.48
LPN hours/ resident / day
3.77
Aide hours/ resident / day
6.71
Total nurse hours/ resident / day
1.25
RN hoursweekends
19.2%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 24 beds and averages 15.9 residents a day — about 66% occupied, or roughly 8 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 6.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.46 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.77 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 5.71 hrs/resident/day on weekends vs 7.12 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.54 to 1.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 19% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

2
deficiencies at the latest standard inspection (2026-02-27)
11
at the previous standard inspection (2024-09-13)

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.

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.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · Ecited before2026-02-27 · 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 stored and/or prepared under sanitary conditions when:A Kitchen Staff was not wearing hair restraint in the kitchen, andUnlabeled packs of bread were found in the food pantry.These failures had the potential to cause foodborne illnesses.Findings:1. During an initial kitchen tour observation and interview on 2/24/26 at 2:12 p.m. with the Executive Chef (EC), the EC verified a Dishwasher (DW) was walking around the kitchen without a hair restraint. The EC stated DW should have worn a hair net. Other staff present in the kitchen during the tour were all wearing a hairnet.A review of facility's policies and procedures (P&P) entitled Uniform Dress Code revised 1/2025, the P&P indicated. Personal cleanliness and a neat appearance are essential for the food service worker. Associates Working with food . wear the approved hair restraint when on duty regardless of length or presence of hair. The only exception is to remove hair restraints when delivering trays to patients/residents. Food service 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-27 · tag F0847 — isolated
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    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 that three out of four sampled residents (Residents 9, 23, and 39), who signed the binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by a neutral arbitrator [third party decision-maker] instead of a judge or jury in court) understood the BAA prior to signing. This failure posed the risk for the residents to make uninformed decisions regarding the right to file an appeal, if there were any allegations of medical malpractice. During a concurrent interview and record review on 2/25/26 at 2:21 p.m. in the activity room with Resident 9, Resident 9 verified her signature on a BAA signed on 1/22/26. Resident 9 stated she did not know about the BAA and was not aware she signed the agreement. Resident 9 stated she just had a surgery prior to signing the BAA. Resident 9 also stated she did not want to give up her constitutional right to have any dispute decided in a court of law. A review of Resident 9's medical records indicated an admission date of 1/21/26. A…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Findings:Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three sampled residents (Resident 1) when Resident 1 received oxygen therapy with no physician's order and there was no oxygen care plan.These failures had the potential to compromise the resident's health and well-being.Review of Resident 1's medical record indicated he was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation (COPD, a progressive, irreversible disease that restricts airflow causing breathing problem); acute respiratory failure with hypoxia (a critical condition where the lungs cannot adequately transfer oxygen to the blood.)Review of Resident 1's Weights and Vital Summary - Vital: O2 [Oxygen] sats [saturation] (a device used to measure how well blood is transporting oxygen throughout the body,) dated 1/12/26 to 1/14/26, the record indicated, Resident 1 was on oxygen via…

    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 · E2024-09-13 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure 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 ensure, one of eight sampled residents (Resident 66), was free of significant medication error, when the physician order for the Lasix (a diuretic, used to reduce fluid retention) medication, of Resident 66 was not followed. This failure had the potential to affect the health and general well-being of the resident. Findings: During an observation and interview with Resident 66 on 9/9/24 at 12:35 p.m., Resident 66 was in her bed with the head of her bed elevated at 90 degrees. Resident 66 was eating her lunch. She verbalized that her Lasix medication was wrongly given last week. The nurses gave it to her three times per day instead of three times per week. Review of the admission record (a document that contains important information about a resident's admission to a healthcare facility) of Resident 66 indicated, Resident 66 was re-admitted to the skilled nursing facility on [DATE] with diagnoses including acute pulmonary edema (a medical…

    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 · E2024-09-13 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure foods were stored in safe and sanitary manner when: 1. Resident foods and food brought by family or visitor stored in the refrigerator at the facility dining area, were readily accessible to all the residents and; 2. Expired food was kept in the cabinet at the facility dining area. These failures had the potential to access the expired food and the food brought by family or visitor in the refrigerator. Findings: 1. During an observation of the skilled nursing facility dining area on 9/9/24 at 3:27 p.m., there was a refrigerator for storage of resident foods. The refrigerator had the following unexpired food items: a. 41 small cups of juices; b. 8 cups of snack packs; c. 2 small cups of diced peaches; d. 4 cups of yogurts (food produced by bacterial fermentation of milk); e. 8 small cups of cranberry juices; f. 9 cans of tomato juices; g. 12 small packs of milk; h. 3 packs of thickened dairy (milk-based) beverages; i. 6 cans of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-13 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide written notification to the Long-Term Care Ombudsman (person who routinely visits the facility and advocates for the residents) for one of two sample discharged residents (Resident 14) when Resident 14 was transferred to the acute care hospital. This failure had the potential to result in the resident not having an advocate who could inform them of their admission, transfer, and discharge rights and options. Findings: Review of Resident 14 clinical record indicated she was transferred to the acute hospital on 8/17/24. There was no documentation in the clinical record indicating the facility notified the Ombudsman regarding this transfer. During an interview with the social service designee (SSD) on 9/13/24 at 1:43 p.m., she confirmed written notification regarding the above transfer was not sent to the ombudsman. The SSD acknowledged the resident's transfer should have been notified to Ombudsman. During a review of the facility's policy and procedure (P&P) titled Transfer, Evacuation, Relocation or Discharge…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-13 · 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 and implement comprehensive person-centered care plans for one of eight sampled residents (Resident 12) when the resident's communication care plan was not person-centered. This failure had the potential for inaccurate development and implementation of person-centered care plans that would address the residents' identified concerns and needs. Findings: Review of Resident 12's clinical records indicated he was admitted on [DATE] with diagnoses including myringotomy tube status (a small tube placed in the ear to treat ear infections and other ear conditions) and bilateral presbycusis (age-related hearing loss). During an interview on 9/09/24 at 10:38 a.m. in his room, he stated he could not hear and needed to use his cellphone, which has a translator function as a communication tool. Review of Resident 12's minimum data set (MDS, an assessment tool) dated 7/15/24 indicated he had a brief interview of mental status (BIMS, a tool used to assess…

    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 before2024-09-13 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's 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 ensure an activity program that met the resident's needs, interests, and preferences was provided to one of eight sampled residents (Resident 11). This failure had the potential to affect the residents' physical, mental, and psychosocial well-being and quality of life. Findings: Review of Resident 11's clinical record indicated she was admitted on [DATE] and had diagnoses including Alzheimer's disease (a progressive brain disorder that destroys memory, thinking skills, and the ability to perform simple tasks) and dementia (a decline in mental capacity affecting daily functioning). Review of Resident 11's minimum data set (MDS, an assessment tool), dated 7/15/24, indicated she was not able to complete the brief interview for mental status. It also indicated Resident 11 felt it was very important to listen to music she liked. During a review of Resident 11's activities care plan, the care plan indicated she has little or no activity…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) assessed and discussed the cause of unplanned weight loss, updated the care plan with a measurable goal and interventions, and provided necessary and timely interventions to maintain the acceptable weights of the residents when there was no follow-up by the IDT after the significant weight loss for one of eight sampled residents (Resident 8). This failure had the potential to result in being unable to evaluate the residents' complete nutritional status and provide necessary interventions timely. Findings: Review of Resident 8's medical record indicated she was admitted on [DATE] with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), hemiplegia (a condition that causes partial or complete immobility on one side of the body), and type 2 diabetes…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-13 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow their bed rails (adjustable rigid bars attached to the side of a bed: side rails, safety rails, and grab/assist bars) policy for one of one sampled resident (Resident 2) when there was no informed consent verification form obtained prior to installing bed rails. This failure had the potential to result in the resident and the resident's responsible parties (RP, individuals designated to make decisions on behalf of the residents) not being fully informed of the use of bed rails. Findings: During an observation on 9/09/24 at 10:13 a.m., the bed of Resident 2 was inspected. The bed had an upper partial bed rail on the left side. During an interview on 9/10/24 at 11:33 a.m., minimum data set coordinator (MDSC) A stated that the facility initiated bed rail for Resident 2 on 7/06/22, removed on 4/25/24, and reinstalled on 5/06/24. Review of Resident 2's physician's order, dated 5/06/24, indicated she use side rails assist bar on the left side of the bed to increase mobility (movement), support self during…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2024-09-13 · 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 interview and record review, the facility failed to document administration of controlled medications (medications controlled by the government because they may be abused or cause addiction) on the controlled medication accountability sheet (count sheet) for one resident (Resident 8). This failure compromised the facility's ability to ensure accurate administration of medications. Findings: During controlled medications accountability check on 9/09/24 at 10:50 a.m. with registered nurse (RN) B, Resident 8's controlled medication accountability sheet indicated the remaining count of lacosamide (an anticonvulsant) 100 milligrams (mg, unit dose of measurement) was 7, but the medication stock count was 6 in a bottle container. RN B stated she counted controlled medications during the shift change this morning but did not open the bottle container to count lacosamide. Review of Resident 8's physician's order, dated 8/12/24, indicated lacosamide 100 mg by mouth two times a day for seizure (abnormal electrical activity in brain). During an interview and record review with…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-13 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure 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

    Based on observation, interview and record review, the facility failed to ensure that recipe for making puree was being followed when the executive chef did not follow the recipe for making chicken teriyaki puree. This failure had the potential to result in decreased palatability that could lead to decrease in food intake for the 2 residents with puree diet order out of the skilled nursing facility census of 15. Findings: During the observation of making puree (smooth, crushed, or blended food that has the consistency of a creamy paste or liquid) with executive chef (EC), on 9/11/24 at 11:32 a.m., EC was making chicken teriyaki (grilled or broiled chicken after being soaked in a seasoned soy sauce marinade) puree. EC put 12 ounces (oz, unit of weight) of chicken teriyaki into the robo coupe blender, added 3 oz of milk and then pureed them. EC then checked the consistency of the pureed chicken teriyaki, and added 2 oz more of milk, then pureed them again. EC placed the pureed chicken teriyaki in the steamed table food container after. Review of the facility's undated, Pureed Recipe,…

    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 · Dcited before2024-09-13 · tag F0847 — isolated
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    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 that one out of five sampled residents (Resident 6), who signed the binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by a neutral arbitrator [third party decision-maker] instead of a judge or jury in court) understood the BAA prior to signing. This failure posed the risk for the resident to make uninformed decisions regarding the right to file an appeal if there was any allegations of medical malpractice. Findings: A review of facility-provided document, it indicated there were five residents (Residents 1, 6, 10, 65, and 66) currently residing in the facility who have entered into a binding arbitration agreement on or after 9/16/19. During an interview with Resident 6 on 9/11/24 at 11:09 a.m., Resident 6 stated he was not aware he had a choice not to sign the BAA during admission. Resident 6 stated, I didn't feel pressured, but I felt I had to sign everything. I just want to be here. Resident 6 also stated, During the admission there were a lot of…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to implement infection control practices for one of eight sampled residents (Resident 165) when staff did not follow the facility's handwashing/hand hygiene policy. This failure had the potential to spread infection in the facility. Findings: During a medication administration observation on 9/10/24 at 4:09 p.m., Resident 165 tried to walk out from her room when Licensed Vocational Nurse (LVN) B wiped a glucometer (a device to check blood sugar). LVN B went into the room and assisted Resident 165 with her bare hands. During an observation on 9/10/24 at 4:13 p.m., Resident 165 with LVN B's assistance came out of the room. LVN B picked the glucometer, put it in its container, and stored the container in the medication cart without performing hand hygiene. During an interview on 9/10/24 at 4:15 p.m. with LVN B, she confirmed the above observation. LVN B stated she should have performed hand hygiene before and after assisting Resident 165 for infection control. During a review of the facility's policy and procedure (P&P) titled…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-07-21 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview and facility document review, the facility failed to ensure the director of dining services (DDS) comprehensively carried out the functions of the food and nutrition services when the DDS did not perform kitchen audits monthly as scheduled. This failure resulted lapses in the delivery of services associated with food safety and sanitation (cross-reference F812) which had the potential transmission of foodborne illness to 16 residents. Findings: During multiple observations at the facility's kitchen on 7/17 through 7/19/2023, there were multiple issues identified with respect to the functions of food and nutrition services (cross-reference F812). 1. Issues with condiments: opened but not labeled or dated; stored beyond used date, and label about storage after opening was not followed. One condiment did not have the right cap to cover the bottle tightly. 2. Issues with improper use of hair restraints: two dietary staff inside the kitchen, were not wearing hair restraints and three other dietary staff were not wearing the hair restraints properly. 3.…

    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 before2023-07-21 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when: 1. The condiments were opened but not labeled or dated, stored beyond used date, label about storage after opening was not followed and one condiment did not have the right cap to cover the bottle tightly; 2. The walk-in freezer's ceiling had ice buildup; 3. Dietary staff did not follow the proper use of hair restraints; 4. A water dispenser was not kept in a sanitary condition; 5. Dishwasher D (DW D) used the expired quat test strips (used to determine that the concentrations of quaternary ammonium [quat-a chemical that kills bacteria, molds, and virus] in sanitizer solutions are at the correct level); 6. There was water pooling in the kitchen floor behind the steamer; 7. There were grayish build up substance behind the steamers, the wheels of oven and some brownish, blackish substance buildup between the hot…

    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 · E2023-07-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that the wheels on the bed of residents were locked for two of five sampled residents (Resident 4 and Resident 220). This failure had the potential to result in accident and injury. Findings: 1. Review of Resident 4's Care Plan, revised on 7/30/22, indicated the resident was at risk for falls related to gait/balance problems, episode of fall. During an observation on 7/18/23, at 8:46 A.M., three out of four wheels of Resident 4's bed were unlocked. During an interview on 7/18/23, at 8:51 A.M., with Certified Nursing Assistant (CNA K), she confirmed the above observation. She also stated that all wheels of the bed should have been locked and at the lowest position. 2. Review of Resident 220's Care Plan, revised on 6/30/23, indicated the resident is at risk for falls related to antihypertensive medication, gait/balance problems, left hip pain, status post fractures of the other parts of pelvis/sacrum. During an observation on 7/18/23, at 12:32 P.M., two out of four wheels on Resident 220's bed were found…

    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 · E2023-07-21 · tag F0727 — failed to provide required RN coverage — pattern
    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 facility's document review, the facility failed to provide a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This failure had the potential to affect resident's care, health, and well-being. Findings: Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report from the Centers for Medicare and Medicaid Services (CMS) dated January 1 - March 1, 2023, it indicated, under Metric, No RN Hours was Triggered on 1/1, 1/15, 2/18 and 3/18/2023. During an interview with the director of nursing (DON) on 7/21/2023, at 8:14 a.m., the DON confirmed the days without an RN. DON stated the only RNs in their facility were her and RN B. DON stated they were hiring an RN, but nobody applied yet. During an interview with the executive director (ED) on 7/21/2023, at 8:45 a.m., the ED stated they were hiring for the RN position since March 2023, but unfortunately, nobody applied. Review of the licensed nurses schedule for the months of January to March 2023, it indicated a confirmation, there were no RN that worked on 1/1, 1/15, 2/18 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-21 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling for one of one medication cart. This failure had the potential to result in the administration of outdated or expired medication. Findings: During a concurrent observation and interview, medication storage cart inspection on [DATE], at 1:05 P.M., with Registered Nurse (RN B) and Nurse Supervisor (NS), an opened box of Omeprazole (a medication for upset stomach) was found. RN B and NS were not able to locate the expiration date label. During a concurrent interview on [DATE], at 3:30 P.M., with NS, she stated she removed the medication from the cart because she was not sure of the expiration date and replaced it with an unopened box with expiration date of 12/2023. During an interview on [DATE], at 9:30 A.M., with Pharmacy Consultant (PC), she stated she highly recommend throwing a medication that have no expiration date. Review of facility's Storage of Medication policy, dated 11/2017, indicated Outdated,…

    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 before2023-07-21 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    3. During an observation, on 7/17/23, at 8:02 A.M., the EST was seen wearing disposable gloves on both hands while cleaning a resident's room. After cleaning, she removed one glove only. She proceeded to hold a plastic bag with soiled rags with the ungloved hand and pushed the cart using the gloved hand towards the end of the hallway. She then went to the dirty utility area carrying the plastic bag. She then came out and opened a closet located in the hallway still with one gloved hand and removed several rolls of toilet paper. After that she then removed the glove. No hand hygiene or hand washing performed. During an interview, on 7/17/23, at 9:26 A.M., EST stated that when cleaning resident rooms, she would perform hand hygiene, wear gloves, use only one rag to mop the floor. She also stated that after cleaning the room, she would remove gloves, rags, garbage and do hand hygiene. During an interview on 7/20/23, at 1:39 PM, with Director of Nursing (DON), she stated that both used gloves should have been removed after any procedure, staff must perform hand hygiene, and hand…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain an organized and sanitary environment for one non-sampled resident (Resident 14) when the bathroom was disorganized, and the toilet bowl was dirty. These failures created a disorganized and unsanitary environment that could pose safety risks for Resident 14. Findings: During a concurrent observation and interview on 7/17/2023, at 9:12 a.m., Resident 14 was on her wheelchair beside the bed. Resident 14's bathroom had the following observations: the sink had an opened dry disposable wipe with one of the wipes outside the package, a clean disposable brief was placed behind the sink's faucet, a kidney basin with Resident 14's toiletries was placed on top of a clean hand towel, an opened box of gloves was in the bathroom floor and the toilet bowl had some stool on the side. Resident 14 stated she goes to the bathroom as needed. During an interview with the director of nursing (DON) on 7/19/2023, at 8:36 a.m., the DON confirmed Resident 14 could walk to the bathroom with assistance. The DON agreed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-21 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification to the Long-Term Care Ombudsman (person who routinely visits the facility and advocates for the residents in the nursing homes) when one of two residents (Resident 18 ) was transferred to the hospital. This failure had the potential to result in the resident not being informed of her rights. Findings: Review of Resident 18's clinical record indicated she was admitted to the facility on [DATE] and was transferred to a hospital on 5/3/23 for further evaluation and treatment. There was no documentation in the record indicating the facility notified the Ombudsman of Resident 18's transfer to the hospital. During an interview, on 7/20/23, at 11:10 A.M., with Director of Nursing (DON), she stated the Social Services Director (SSD) responsibility to notify the Ombudsman regarding Resident 18. During an interview, on 7/20/23, at 11:20 A.M., with SSD, she stated that she notified the Ombudsman for planned discharges. She also 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-21 · tag F0641 — isolated
    Ensure 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 and record review, the facility failed to accurately code the minimum data set (MDS, an assessment tool) assessment for one of 13 sampled residents (Resident 7) when Resident 7's completed and transmitted quarterly MDS did not reflect Resident 7's hospice care. These omissions in coding resulted in an inaccurate MDS and not addressing the resident needs. Findings: Review of Resident 7's admission Record indicated, Resident 7 was admitted to the facility with diagnoses including encounter for palliative care (hospice care) dated 11/25/2022, congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), dementia (decline in mental capacity affecting daily function), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and dysphagia (difficulty swallowing). During a concurrent interview and record review with the MDS nurse (MDSN) on 7/21/2023, at 8:34 a.m., the MDSN confirmed Resident 7 was 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-21 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's 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 provide an ongoing activity program that meet the resident's needs, interests, and preferences for one of 13 sampled residents (Resident 11) when Resident 11's activity care plan was not updated and implemented. This failure had the potential to affect the resident's physical, mental, psychosocial well-being, and self-worth. Findings: During multiple observations on 7/17, 7/18, 7/19, 7/20/2023, between 8:20 a.m. to 11:11 a.m., Resident 11 was lying in bed, and did not have any activities. Review of Resident 11's admission Record, indicated, Resident 11 was readmitted to the facility on [DATE] with diagnoses including left hip fracture, diabetes mellitus (a condition which affects the way the body processes blood sugar), Alzheimer's disease (a type of dementia which is a progressive disease that destroys memory and mental functions) and repeated falls. Review of Resident 11's Significant Change in Status Assessment Minimum Data Set (SCSA…

    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 · D2023-07-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 respiratory care for one of one sampled resident (Resident 4) in accordance with professional standards of practice and facility's policy and procedure when a Certified Nursing Assistant A (CNA A) administered oxygen (a colorless and odorless gas that people need to breath) to a resident. This failure had the potential for unsafe oxygen administration and negatively affect the resident's health and safety. Findings: Review of Resident 4's clinical record indicated she was admitted on [DATE] and had a diagnosis of chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), hypoxemia (a low level of oxygen in the blood). Review of Resident's 4's physician order indicated To administer 2 liters continuously to keep oxygen saturation (the amount of oxygen circulating in the blood) above 92 percent and for shortness of breath. During an observation on 7/17/23, at 12:22 P.M., the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-21 · 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 five sampled residents (Resident 7) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 7 received Lorazepam (a medication for anxiety) without documentation of its specific duration in the resident's clinical record. This failure had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the residents physical, mental, and psychosocial well-being. Findings: Review of Resident 7's admission Record indicated, Resident 7 was admitted to the facility with diagnoses including encounter for palliative care (hospice care) dated 11/25/2022, congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), dementia (decline in mental capacity affecting daily function), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), delirium ( and dysphagia (difficulty…

    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 5 of 54.2+0.8 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 04/01/2021
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
BANNER, RYANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/17/2025
BEHNAM, SHAIDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/14/2024
ICHIEN, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/27/2026
MACANGO, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/04/2026
MCMULLIN, MARYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
NABOR-ANDOY, MERZAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/24/2022
OLSON, KARIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021

CMS files one row per role, so the 27 rows in the source record cover these 22 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.

$3.2M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
$677K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 41%Other / private 59%

This home reported $677K 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

$2,350per resident / day
operating cost
$71,446per month
≈ monthly operating cost
$527per 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 055303. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-27, 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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