No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Forest Hill Manor Health Center

551 Gibson Avenue, Pacific Grove, CA 93950 · For profit - Limited Liability company · 26 certified beds · (831) 657-5200 Medicare & Medicaid certified

Call the home — (831) 657-5200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$8,278 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,278 in federal fines (most recent 2025-10-01)
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

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

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

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 fell from 5 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Short-stay residents who newly got an antipsychotic medication0.8%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission32.5%23.0%22.6%worse
Short-stay residents with an outpatient ER visit10.7%11.2%12.0%better

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.

64.8% 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 329 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

64.8%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
72.9%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 72.9% 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 107 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNF64.8%CMS range 58.9–69.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 7.1–12.510.7%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 discharge72.9%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 discharge71.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge65.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%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 setting100.0%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 discharge67.4%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 stay1.3%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 worsened2.1%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 hospitalization9.3%CMS range 6.4–12.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.041.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.90
RN hours/ resident / day
1.35
LPN hours/ resident / day
2.79
Aide hours/ resident / day
5.04
Total nurse hours/ resident / day
0.46
RN hoursweekends
44.4%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 26 beds and averages 24.6 residents a day — about 95% occupied, or roughly 1 bed 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 5.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.79 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 4.35 hrs/resident/day on weekends vs 5.32 on weekdays — 18% thinner on weekends. RN hours go from 1.08 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.

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

Inspection trend

6
deficiencies at the latest standard inspection (2025-04-25)
12
at the previous standard inspection (2024-01-23)

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.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · G2025-10-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident received adequate monitoring to prevent an elopement (leaving the facility without authorization) for one of two sampled residents (Resident 1). Resident 1's elopement assessment indicated she was at risk for elopement, and a care plan was not developed upon admission. On 6/27/25, Resident 1 eloped, was found the next day on 6/28/25 in the neighborhood, transferred to a hospital, was noted to have hypothermia (significant and potentially dangerous drop in body temperature with most common cause from exposure to cold weather) and sustained injuries of forehead laceration (cut) requiring suturing.This failure resulted in Resident 1 having multiple bodily scratches/abrasions, hypothermia, altered mental status, rhabdomyolysis (breakdown of muscle tissue that releases a damaging protein into the blood), forehead laceration and urinary tract infection.Findings:Review of Resident 1's Nurse's Note, dated 6/27/25 at 11:23 p.m.,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-10 · 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 Based on interview and record review, the facility failed to ensure services were provided that meet professional standards of quality when assessments of pressure sores were incomplete for 2 of 3 residents (Residents 1 & 2). This failure had the potential to compromise Residents' health and safety. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control), peripheral vascular disease (PVD, slow progressive narrowing of the blood flow to the arms and legs), Protein Caloric Malnutrition (PCM, condition resulting in inadequate intake of protein and calories, and chronic kidney disease (CKD, a condition where kidneys cannot properly filter blood in the body). Review of Resident 1's initial body check on 3/14/26 indicated, she had stage 2 sacral pressure ulcer (partial-thickness loss of skin, presenting as a shallow open sore or wound over the tail bone) measuring 0.3 centimeter (cm, unit of measurement)…

    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 · Fcited before2025-04-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. There were opened, undated, and unlabeled food items in the reach-in refrigerator; 2. There were undated and unlabeled food items in the food preparation area; 3. Pans used for food preparation and food service were stacked and stored wet. These failures had the potential to cause food contamination and food-borne illness to 24 of 24 residents who received their food from the kitchen. Findings: 1. During an initial kitchen tour on 4/21/25 at 9:20 a.m., accompanied by the registered dietician (RD), the following observations were made in the reach-in refrigerator: The following items were opened and undated: - 1 gallon of milk - 1 32-ounce carton of liquid eggs - 3 5-pound containers of sour cream - 1 gallon of Italian dressing and 1 gallon of coleslaw dressing - 1 gallon of maple syrup The following items were opened, undated, and unlabeled: - 3 pitchers containing yellow, orange 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-25 · tag F0755 — failed to provide safe pharmacy services — pattern
    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 ensure accurate accountability of controlled drugs (medications that can be easily abused and are under strict government control) to document medication administration as in accordance with the facility policy and procedures (P&P) and the availability of medication for three out of 13 sampled residents (Resident 10, Resident 9, and Resident 15). These failures had the potential for medication errors and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally) and had the potential for untreated or worsening of patient's medical conditions. Findings: 1. A review of Resident 10's clinical record indicated Resident 10 was admitted to the facility with diagnoses including anxiety (Intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 10's physician's order indicated an order, dated 3/27/25, for diazepam (it can treat anxiety)5 mg (milligram, unit of measurement), 1 tablet by mouth every 8 hours as needed for anxiety for 14 days.…

    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 before2025-04-25 · 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

    Based on observation, interview, and record review, the facility failed to ensure proper medication storage when the medication refrigerator temperature is below the acceptable range of 36 Fahrenheit (F) to 46 (F). These failures had the potential for residents to receive medications with reduced efficacy. Findings: On 4/21/25 at 9:46 a, m., an inspection of the medication refrigerator in Medication Room with the Director of Nursing (DON) observed the built up of thick ice inside the medication refrigerator and the temperature was 32 F. There were medications inside the refrigerator. The DON confirmed these findings, she stated the ice built up inside the medication refrigerator should not be that thick. During a follow inspection of medication refrigerator inside the Medication room on 4/21/25 at 1:57 p.m., with the DON, The DON checked the refrigerator temperature, and she stated the temperature was 28 F, she further stated the acceptable range for medication refrigerator temperature is 36 F to 46 F. She stated she will call the pharmacy. The DON confirmed the Medications inside…

    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 · D2025-04-25 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure dignity and privacy was upheld for one of two sampled residents (Resident 179) when Resident 179's Foley catheter drainage bag, (a device inserted into your bladder [organ that collects urine] to drain urine if you cannot urinate on your own made of a semi-flexible plastic tube, one end inserted into the bladder and the other end attached to a bag that collects urine) drain bag was left uncovered. This failure had the potential for adverse effects on the psychosocial well-being and health of Resident 179. Finding: During an observation on 4/21/25 at 10:46 a.m., in Resident 179's room. Resident 179 was observed lying on her bed. Her Foley catheter drainage bag was on the floor and the bag was left uncovered, yellow colored urine was visible from drainage bag. During a review of Resident 179's clinical record indicated Resident 179 was admitted to the facility with diagnosis including retention of urine (when bladder doesn't empty completely or at all). During a review of Resident 179's physician's order…

    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 · D2025-04-25 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure one of 13 sampled residents (Residents 19) were free from unnecessary medication when Resident 19 received Lasix (used to treat edema [fluid retention; excess fluid held in body tissues]) without monitoring. This deficient practice resulted in unmonitored medical condition. Finding: During a review of Resident 19's clinical record indicated Resident 19 was admitted to the facility with diagnosis including Diastolic congestive heart failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). A review of Resident 19's physician's orders indicated an order for Lasix 20 mg, 1 tablet by mouth every 48 hours for swelling on feet, dated 4/12/24. A review of Resident 19's medication administration record (MAR) indicated the nursing staff did not monitor for swelling on the feet. During a concurrent interview and record review on 4/23/25 at 3:12 p.m., with the Director of Nursing (DON), the DON reviewed Resident 19's physician's orders and confirmed there was no…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection prevention practices were followed for two of seven residents (Resident 83 and 179) when: 1. Resident 83's intravenous (IV, within or into a vein) tubing was undated; 2. A Certified Nursing Assistant not wearing wearing Personal Protective Equipment (PPE, its equipment worn to minimize exposure to hazards in the workplace) during patient care and; 3. Resident 179's Foley catheter drainage bag (a device inserted into your bladder [organ that collects urine] to drain urine if you cannot urinate on your own made of a semi-flexible plastic tube, one end inserted into the bladder and the other end attached to a bag that collects urine) was on the floor and uncovered. These failures had the potential to place the residents at risk for developing an infection and the potential to result in transmission of infection in the facility. Findings: 1. Review of Resident 83's clinical record indicated he was admitted to the facility 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-01-23 · tag F0700 — widespread
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their bed rails (bed rails, safety rails, side rails, grab/assist bars: adjustable metal or rigid plastic bars that attached to the bed) policy for 12 of 12 sampled residents (Residents 8,178, 179, 184, 181, 12, 132, 4, 20, 7, 13, and 6). The survey team expanded the sample and identified that a total of 25 resident had the bed rails. The facility failed to follow their bed rails policy when: 1.There was no documentation that alternatives for bed rails were attempted prior to installing bed rails for 25 of 25 residents; 2.There was no informed consent (the process of communication between health care provider and resident that often leads to agreement or permission for care, treatment or services or interventions) from residents or responsible parties (RP, individuals designated to make decisions on behalf of the residents) prior to installing bed rails for 16 of 25 residents (Residents 183, 181, 8, 187, 186, 182, 180, 3, 132, 128,…

    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 · Fcited before2024-01-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. The convection oven (a cooking device that heats food) located in the skilled nursing facility (SNF) pantry area was not kept in a sanitary condition; 2. No thermometer inside the freezer designated for the SNF residents; 3. The freezer temperature log was not completed, and multiple times, the temperature was 1-2 degrees above 0 Fahrenheit (F, a scale of temperature) degree; 4. The freezer designated for the SNF residents had multiple items unlabeled; 5. An opened bag of pasta was not labeled in the dry storage area; 6. The ice machine was not kept in a sanitary condition; 7. One faucet of the main kitchen was not well maintained; These failures had the potential to cause cross-contamination of food (cross-contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness), the growth of microorganisms, and foodborne illness for the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-23 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility had a 10.53 percent (%, unit of measurement) medication error rate, when 4 medication errors occurred out of 38 opportunities during the medication administration, for three out of nine residents (Residents 12, 4 and 185). These failures resulted in the medications, not given in accordance with the prescriber's orders, manufacturer's specifications and medication administration's instructions, which resulted in residents, not receiving the full therapeutic effect of the medications or the proper administration of the medication and may cause preventable side effects for the residents. Findings: 1. During the medication pass observation of Resident 12 with licensed vocational nurse C (LVN C), on 1/16/24 at 12:30 p.m., there was no available hydralazine hydrochloride (used to treat or control high blood pressure) tablet and LVN C was not able to administer the hydralazine hydrochloride oral tablet medication to Resident 12 because it was not…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Ecited before2024-01-23 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, infection control practices were implemented when: 1. Licensed vocational nurse C (LVN C) did not sanitize the blood pressure cuff and pulse oximeter, before she used them on Resident 12; 2. There was a personal food, placed on top of the medication cart 2; and 3. Resident 4's oxygen tubing had no label and was found on the floor. These failures could result in the spread of infection and cross-contamination that could affect the 25 residents residing in the facility. Findings: 1. During the medication pass observation with licensed vocational nurse C (LVN C) on 1/16/24 at 12:25 p.m., LVN C took Resident 12's blood pressure (measure of how forcefully, the blood goes through the arteries) and heart rate (frequency of heartbeat) prior to the administration of hydralazine hydrochloride (used to treat or control high blood pressure) and isosorbide dinitrate (used to treat heart failure) oral medications. LVN C did not sanitize…

    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 · D2024-01-23 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 follow their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney [a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) and completion of physician orders for life-sustaining treatment (POLST, a document that specifies the medical treatments the resident wants to receive during serious illness) form for five of seven sampled residents (Residents 8, 178, 179, 181, and 184). This failure could lead to the delivery of unnecessary or inappropriate medical services against Residents 8, 178, 179, 181, and 184 goals and wishes. Findings: Review of Resident 8's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's clinical record indicated, there was no advance directive. Review of social services notes indicated there…

    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 · D2024-01-23 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pre-admission screening and resident review (PASRR- screening for residents with a mental disorder [MD, a wide range of conditions that affect mood, thinking, and behavior] and residents with intellectual disability [ID, when there are limits to a resident's ability to learn at an expected level and function in daily life] or related disorders [RD]) screening was completed for one out of two residents. This failure had the potential for Resident 8 not to receive the required care and services. Findings: Review of Resident 8's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD, a psychiatric disorder that may occur in residents who have experienced or witnessed a traumatic event or set of circumstances). Review of Resident 8's history and physical document from acute hospital (where residents receive…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-23 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan for two out of 12 sampled residents (Residents 4 and 20) within 48 hours of the resident's admission when: 1. For Resident 4, there was no care plan to address oxygen use; 2. For Resident 20, there was no care plan for bowel and bladder incontinence; 3. For Resident 20, there was no care plan to manage blood sugar to prevent hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). These deficient practices had the potential for delayed administration of necessary care and services. Findings: 1. Review of Resident 4's clinical record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including acute diastolic heart failure (the left ventricle muscle becomes stiff or thickened and shortness of breath with exertion or when lying down). Review of Resident 4's physician's order summary indicated administer oxygen 2 l/min (l/min, liter per minute) as needed, starting on 12/26/23. During an…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-23 · 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 ensure to follow physician's order for oxygen (colorless, odorless, and tasteless gas supports life) rate administration for one of three sampled residents (Resident 181). This failure had the potential to compromise Resident 181's health, and well-being. Findings: Review of Resident 181's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 181 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (when lungs are unable to pass enough oxygen to the blood, or when fail to remove carbon dioxide [colorless and odorless gas humans breathed out] from the blood), acute pulmonary edema (fluid build up in the lungs), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), and obstructive sleep apnea (intermittent airflow blockage during sleep). Review of Resident 181's physician's order dated 1/7/24 indicated,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a physician's order for a PRN (as needed) psychotropic medication (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days of use and failed to obtain an informed consent for one of 12 sampled residents (Resident 4). These failures had could lead to the administration of unnecessary medication to the resident. Findings: Review of Resident 4's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations) and unspecified depression. Further review of Resident 4's clinical record indicated a physician's order, dated 12/20/23, for Diazepam 10 milligrams (mg., a unit of measurement) every 8 hours as needed (PRN) for anxiety. The order did not have a stop date. During a concurrent interview and record review with the infection preventionist (IP) on 1/18/24 at 2:35 p.m., the IP reviewed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-23 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, discontinued medications were properly discarded and not kept in the medication cart when: 1. For Resident 2, discontinued 30 tablets of montelukast sodium (medication used to prevent breathing difficulties) 10 milligram (mg, unit of measurement), and 53 tablets of hydrocodone-acetaminophen 5-325 (controlled medication for pain) mg, were kept in medication cart 2; and 2. For Resident 78, discontinued 26 tablets of oxycodone hydrochloride (controlled medication for pain) 5 mg, and 23 capsules of pregabalin (controlled medication that can treat nerve and muscle pain), 25 mg, were still in medication cart 2. These failures had the potential for residents to receive discontinued medications and controlled medication diversion. Findings: During an observation and inspection of medication cart 2 with the minimum data set coordinator (MDSC), on 1/17/24, at 2:35 p.m., noted discontinued 30 tablets of montelukast sodium 10 mg, and 53…

    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 · D2024-01-23 · tag F0801 — isolated
    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 staff interviews and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of qualified, full-time personnel to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food-borne illness for 25 residents eating facility-prepared foods. Findings: During an interview with the registered dietitian (RD)on 1/16/24 at 11:56 a.m., the RD stated that he was a part-time employee of the skilled nursing facility (SNF). The RD further stated the kitchen belongs to the Assistant Living(AL), under a different company and all the kitchen staff, including the dietary service director were under the AL. During an interview 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-23 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 accommodate food preferences, and food allergies for two out of seven sampled residents (Resident 7, and 4), when: 1. For Resident 7, milk was not provided in her lunch tray, and; 2. For Resident 4, she was allergic to egg whites and had eggs in her breakfast tray. This failure had the potential for decreased meal intake, adverse effects from food allergies, and negative effect on health and well-being for sampled residents. Findings: During lunch observation in the facility's dining room on 1/16/24 at 12:18 p.m., noted Resident 7 had only one glass of water with ice next to her lunch plate. During an interview with Resident 7 on 1/16/24 at 12:24 p.m., Resident 7 stated there was no milk served for lunch and prefers milk during lunch every day. During a concurrent interview, and record review of Resident 7's lunch tray card with the activity director/restorative nursing assistant (RNA, interact with residents, provide, maintian physical…

    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 · E2022-08-05 · tag F0800 — pattern
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide the chosen foods indicated on resident's lunch meal ticket for three of 8 residents (Residents 3, 216, and 217) and the facility staff did not puree (very smooth, crushed or blended food) foods with fluids which provided flavor and/or nutritional value for one of 8 residents (Resident 2). These failures had the potential to affect the physical health and well-being of residents in the facility. Findings: 1. Review of Resident 3's clinical record indicated, resident had diagnoses including Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), pressure ulcer (an injury to the skin caused by prolonged and constant pressure) of sacral region (located below the lumbar spine and above the tailbone), cellulitis (common bacterial infection) of buttock. During a meal observation and interview on 08/1/2022, at 12:43 PM, while at resident's room. Resident was slowly eating the penne sausage casserole.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-08-05 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. Store bought salad dressings, pickle relish and yogurt were opened and not labeled; 2. Refrigerator in the skilled nursing facilities (SNF) prep kitchen had drinks unlabeled. 3. An ice machine was not kept in a sanitary condition. 4. Frying station had some black, brown, and white sticky build up on its sides and kitchen flooring was not well maintained; 5. The microwave oven located in the skilled nursing facility (SNF) prep kitchen was not kept in a sanitary condition; 6. SNF waitstaff did not practice proper hand hygiene; 7. Canned food and oatmeal containers were dented and stored in a ready to use storage; 8. Food containers were stacked up wet; 9. Carton of milk from resident's refrigerator not labeled. These failures had the potential to cause cross contamination of food (cross contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-08-05 · 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

    Based on observation, interview and record review, the facility failed to implement infection control practices when: 1. The licensed vocational nurse A (LVN A) did not perform hand hygiene before preparation of medications and before donning (putting on) and after removal of gloves during medication administration for residents 167, 67, and 217. 2. The licensed vocational nurse B (LVN B) did not perform hand hygiene during wound and supra pubic catheter (SPC- a device that is inserted into bladder to drain urine) care for Resident 15. These failures had the potential for residents, staff, and visitors at risk of possible spread of infection. Findings: 1a. During a medication administration observation on 8/2/2022 at 8:06 a.m., the LVN A did not perform hand hygiene prior to Resident 167's medication preparation. The LVN A went inside Resident 167, donned a pair of gloves, repositioned Resident 167, administered her medication and removed the used gloves. The LVN A was not observed performing hand hygiene before donning a new pair of gloves and after removal of used gloves. 1b.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-05 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 Depakote (drugs that affect brain activities associated with mental processes and behaviors, example is antipsychotics) was administered with informed consent (form indicating who and when the risks and benefits of a medication were explained to the resident or the family member) for one of the five residents (Resident 167). This failure had the potential of not honoring resident's rights to be informed about her treatment. Findings: A review of Resident 167's clinical record indicated, Resident 167 was admitted to facility with diagnoses including generalized anxiety (a type of mental health condition), right femur fracture with nailing (broken right thigh bone with surgical repair), and dementia with behavior disturbance (decline in mental capacity affecting daily function). A review of Resident 167's physician order, indicated, Depakote (commonly use psychotherapeutic medication to treat dementia with behavior disturbance) 125 milligrams (mg, a metric unit of mass) one tablet, delayed release by mouth three times…

    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 · D2022-08-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Residents 9 and 67) received the appropriate care and services when: 1. For Resident 9, facility staff did not perform resident's HgbA1c test (hemoglobin (protein in red blood cells that carries oxygen) A1C test, a simple blood test that measures your average blood sugar levels over the past 3 months) as ordered; and 2. For Resident 67, nursing staff did not remove resident's lidocaine patch (used to help relieve pain) as ordered. These failures had the potential to affect the health and well-being of the residents in the facility. Findings: 1. Review of Resident 9's clinical record indicated, resident had diagnoses including Type 2 diabetes mellitus (high blood sugar (glucose) with diabetic polyneuropathy (a type of nerve damage that can occur if you have diabetes). Review of Nutrition Reccomendation, dated 7/7/2022, indicated, Reccomendation: Suggest order HgbA1c. Reason: Would like to see if HgbA1c has normalized due to weight loss. Physician's response: Approved…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-05 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet resident's needs when: 1) License vocational nurse A (LVN A) provided an expired protein supplement to Resident 67; 2) Medications were not given to Resident 15 and Resident 9 due to unavailability; 3) The emergency kit (e-kit, a box containing the emergency supplies and medications needed to provide treatment) were not replaced in a timely manner. These failures had the potential to result in not being able to meet resident's needs especially in times of emergency. Findings: 1. A review of Resident 67's clinical record titled, August 2022 Physician Order Sheet, indicated, Pro-Stat AWC (Protein supplement for wound care) 17 gm (gram - unit of measurement)-100kcal (kilocalories - unit of energy)/30ml (milliliters - unit of volume) oral liquid (30 ml) LIQUID (ML) Oral (by mouth), and two times daily for fourteen days starting 07/27/2022. During a concurrent observation and medication label review on 8/2/2022 at 8:35 a.m., the licensed vocational nurse prepared and provided…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-05 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility had a 5.41 percent (%, unit of measurement) medication error rate when two medication errors out of 37 opportunities were identified during medication pass for two of six residents (Resident 15 and 9). These failures had the potential to result in an ineffective drug therapy. Findings: 1. A review of Resident 15's clinical record titled, August 2022 Physician Order Sheet, indicated, indicated, Nexium 40 mg (milligram-unit of measurement) capsule, delayed release (1) CAPSULE, DELAYED RELEASE (ENTERIC COATED) [a coating applied to medication to prevent the drug from stomach's acid or to protect the patient from the direct effect of the drug] for GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS (GERD - happens when the stomach contents come back up into the esophagus) once daily starting on 07/08/2022. During a medication administration observation and interview on 8/2/2022 at 8:15 a.m., the licensed vocational nurse A (LVN A) prepared a total of nine tablets for Resident 15. The LVN A stated, the scheduled Nexium 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-08-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored and labeled appropriately when: 1. Improper storage of an emergency kit (e-kit, a box containing medication needed for immediate administration) containing C-II medications (Classification by the Drug Enforcement Agency: C-II or Schedule II substance is considered to have a high potential for abuse); 2. Controlled medication for one discharge resident was found inside the medication refrigerator. These failures had the potential for drug diversion. Findings: 1. During an observation inside the facility's medication room on 8/1/2022 at 12:59 p.m. with licensed vocational nurse B (LVN B), there were three e-kits found in a locked cabinet. The e-kit containing C-II medications was located on top of the locked cabinet. Inside the cabinet were other house supply medications like vitamins, supplements, and pain relievers. During the medication room observation and interview with the medical staffing coordinator (MSC) on 8/1/2022 at 1:19 p.m., the MSC's office 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.

    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

$8,278 in federal fines across 1 penalty.

  • $8,278 — penalty dated 2025-10-01

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to BVHC, LLC — 12 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 4 of 53.3+0.7 vs chain
Health inspection 3 of 53.0≈ chain avg
Staffing 4 of 53.4+0.6 vs chain
Quality measures 5 of 53.8+1.2 vs chain
The other 11 homes this chain runs (chain average 3.3★, 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 / managerTypeRoleSince
ACOSTA, MARIAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/16/2025
CALABAZARON, REDENTORIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/14/2022
CHINTHAKINDI, RAVIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/21/2022
FUENTES, RAYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/06/2022
PIQUE, JANNETIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/23/2023
TAYLOR, RYANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/08/2023
THAPA, NISCHALIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/06/2024

CMS files one row per role, so the 14 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — 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.

$6.9M
Net patient revenuemost recent cost report
+24.8%
Operating marginrevenue minus expenses
$417K
Related-party expense8% of expenses

This home reported $417K 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

$605per resident / day
operating cost
$18,394per month
≈ monthly operating cost
$805per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555867. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-25, 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.

What to do next