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The Springs Healthcare Center At The Carlotta

41505 Carlotta Drive, Palm Desert, CA 92211 · For profit - Limited Liability company · 59 certified beds · (760) 610-0295 Medicare & Medicaid certified

Call the home — (760) 610-0295 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Jun 20251 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
VA Clinic0.9 mi
41990 Cook St · (760) 341-5570 · Call to confirm hours
Pharmacy
75071 Saint Charles Pl Ste B · (866) 411-4568 · Call to confirm hours
Grocery
42150 Cook St · (760) 837-1877 · Call to confirm hours
Park
74855 Country Club Dr · (760) 341-1868 · Typically dawn to dusk
Place of worship
42575 Melanie Pl · (317) 244-3974

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased2.6%10.2%15.4%better
Long-stay residents who lose too much weight0.0%4.0%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
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 on antianxiety or hypnotic medication10.3%13.7%18.9%better
Long-stay residents with pressure ulcers0.0%4.3%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control14.7%10.2%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table0.0%12.0%17.1%check this — see note marked star below the table
Short-stay residents who newly got an antipsychotic medication0.2%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine93.6%93.2%79.4%better
Short-stay residents rehospitalized after admission31.5%23.0%22.6%worse
Short-stay residents with an outpatient ER visit14.7%11.2%12.0%worse

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

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

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

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

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

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

62.5% 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 397 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.5%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
72.3%U.S. median 56.6%
Met the expected recovery
0.90U.S. median 0.31
Therapy hours / resident / day
0.45hours / resident / day
Physical therapy
0.37hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 72.3% 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 94 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 0.90 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 52% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.5%CMS range 57.6–66.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 7.2–12.410.7%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 discharge72.3%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 discharge72.3%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 discharge59.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.1%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 discharge94.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.6%CMS range 6.6–12.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 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

0.51
RN hours/ resident / day
1.56
LPN hours/ resident / day
2.53
Aide hours/ resident / day
4.60
Total nurse hours/ resident / day
0.30
RN hoursweekends
45.0%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 59 beds and averages 43.0 residents a day — about 73% occupied, or roughly 16 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 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 4.19 hrs/resident/day on weekends vs 4.76 on weekdays — 12% thinner on weekends. RN hours go from 0.59 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% 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 (2025-06-06)
5
at the previous standard inspection (2024-05-02)

Deficiencies are more than at the previous inspection — worsening. 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.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2024-06-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide treatment and services consistent with the professional standards of practice, to prevent progression of pressure injuries (PI-damage to the skin and underlying tissue due to prolonged pressure) for two of three sampled residents (Residents 1 and 2) when: 1. For Resident 2, a consistent weekly skin assessment was not completed to evaluate the changes in the resident's redness to the coccyx identified on admission. In addition, the facility failed to initiate treatment for Resident 2's redness to the coccyx upon admission. These failures resulted in Resident 2's coccyx (tailbone) redness to worsen into a Stage 3 pressure injury (full thickness tissue loss). 2. For Resident 1, a consistent weekly skin assessment was not completed to evaluate the changes in the resident 's Stage 2 PI (shallow opening with loss of middle layer of skin) of the coccyx and left buttocks, and reddened sacrum (is a triangle-shaped bone between your hip bones) identified…

    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 before2026-01-28 · 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 staff were wearing the N95 Respirator (a tight fitting disposable mask that filters out at least 95% of airborne particles including virus') they were approved to wear during Fit Testing (testing that determines the exact make and model of the N95 mask to be worn) for two out of three staff.This failure had the potential for the spread of COVID-19 (A contagious virus spread through respirator droplets) to other residents and staff in the facility. Findings: On January 28, 2026, at 10:05 a.m., an observation of a sign at the facility entrance indicated, . (The facility) currently (has) Covid cases in the building .we ask that you wear a mask during your visit . On January 28, 2026, at 10:43 a.m., an interview was conducted with Registered Nurse (RN) 1 who stated, due to positive COVID-19 cases in the facility, staff are required to wear an N95 mask throughout their shift. The RN stated the facility fit tests to ensure staff wear 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure STAT (immediately) urinalysis (UA) and urine culture and sensitivity (C&S-isolation of microbes and sensitivity to drugs for treatment) specimens were pick up by the laboratory (Lab) within the time frame of 4-6 hours, for one out of three residents (Resident 1).This failure could have resulted in a delay in laboratory values being reported to the residents physician and a delay in necessary treatment for Resident 1.Findings:A review of Resident 1's Patient Information, indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of osteomyelitis (infection of the bone).A review of Resident 1's Brief Interview of Mental Status (A cognitive assessment), indicated Resident 1 had a score of 15, cognitively intact.A review of Resident 1's Progress Notes, dated November 9, 2025, at 6:18 p.m., by Licensed Vocational Nurse (LVN) 1 indicated, . (Resident 1) has had a change of condition (COC-a deviation from baseline clinical…

    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 · D2025-08-19 · 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 interview and record review, the facility failed to provide a safe environment for one of three residents reviewed (Resident 1), when the resident left the facility unnoticed by facility staff. Later, an unknown visitor notified a staff member that Resident 1 left the facility Against Medical Advice (AMA). This failure resulted in Resident 1 not receiving information regarding the risks of leaving AMA which put Resident 1 at risk of possible worsening of her health condition while being outside of the facility setting, and resulted in the staff not knowing Resident 1 had left the facility.Findings:On August 18, 2025, an unannounced visit was made to the facility for a quality-of-care issue.On August 18, 2025, at 10:17 a.m., an interview was conducted with Resident 1's Representative (RR)1, who stated he and RR 2 had Power of Attorney (POA - legally designated person to act on behalf of another person should the person become incapacitated) for Resident 1, and on August 9th, 2025, Resident 1 left 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 · Ecited before2025-06-06 · 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 maintain a sanitary environment, store, and prepare food in accordance with professional standards for food service safety when: 1. Multiple large plastic pans stacked in the storage rack were wet; and 2. Four containers of five pounds (lbs - a unit of measurement) low fat cottage cheese were stored in the refrigerator beyond the use-by-date. These failures had the potential to result in cross contamination (bacteria were unintentionally tranferred from one substance or object to another with harmfull effect) and foodborne illnesses (illnesses that result from ingesting contaminated food) for 40 of 40 medically compromised residents who received food from the kitchen. Findings: 1. On June 3, 2025, at 10:25 a.m., a concurrent observation and interview was conducted with the Dietary Manager (DM) during inspection of the stacked large plastic pans in the storage rack. During inspection, multiple large plastic pans were observed being wet. The DM stated the large plastic pans were not supposed to be wet. 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 · E2025-06-06 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when one re-cycle dumpster lid was widely open, bags of trash were piled and was overflowing one trash container causing the lid not to close, and multiple debris and trash were on the ground. This failure had the potential to attract pests and rodents that can be a source of communicable diseases. Findings: On June 3, 2025, at 11:36 a.m., a concurrent observation and interview was conducted with the Dietary Manager (DM), during inspection of the outside garbage storage area. The following were observed: - One of two blue re-cycle bins had its lid open; - One of four black dumpsters container was overflowing with bags of trash causing the lid not to close; and - Debris and trash were observed on the ground including multiple wood pallets. The DM stated the bags of trash should always be inside the dumpster with the lid closed. She stated the ground should be kept clean from debris. On June 3, 2025, at 1:56 p.m., The Maintenance Director (MD) was interviewed. The MD…

    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 before2025-06-06 · 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 for four of 40 residents reviewed (Residents 17, 92, 11 and 195), when: 1a. For Resident 17, on Enhanced Barrier Precaution (EBP - an infection control precaution using the Protective Personal Equipment (PPE) such as gown and gloves during high contact resident care activities) the Physical Therapist (PT- healthcare professional who helps individuals improve their movement and functions through various therapies) did not wear the proper PPE when transferring Resident 17 from the wheelchair to the bed; 1b. For Resident 92, on EBP, the Certified Nursing Assistant (CNA) did not wear proper PPE when providing care and changing bed linens; 2. For Resident 11, on EBP, the Licensed Vocational Nurse (LVN) did wear proper PPE when providing Foley (a thin flexible tube inserted through the bladder to drain urine when normal urination is not possible) catheter care; and 3. For Resident 195, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-06 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 two of five sampled residents (Residents 11 and 143) were free from unnecessary psychotropic (drug that affects brain activities associated with the mental processes and behavior) medications when: - For Residents 11 and 143, there was no documented evidence the non-pharmacological interventions (NPI, non-drug alternatives) were attempted, including any trial or evaluation of behavioral, environmental, or person-centered approaches, prior to the initiation of psychotropic medications. Furthermore, there was no documentation indicating non-pharmacological interventions were being implemented and monitored in conjunction with the ongoing, daily administration of psychotropic medications; and - For Resident 11, the facility did not have the prescriber-documented rationale for extended use of the as-needed (PRN) temazepam (a psychotropic medication used for inability to fall asleep) beyond 14 days. These failures had the potential to result in…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-06 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the accurate administration of medication in accordance with the physician's order, when a tablet of enteric coated (EC, protective coating designed to dissolve in the small intestine rather than the stomach) aspirin (used to lowers the risk of a heart attack, stroke, or blood clot) was administered to Resident 291 in place of the prescribed order for a chewable aspirin. This failure had the potential for Resident 291 to experience delayed absorption (the time it takes for a medication to be absorbed into the body) and delayed onset (the time it takes for a medication to start working) of aspirin's effect, as enteric coated aspirin is designed to dissolve slowly in the small intestine, whereas chewable aspirin is absorbed more quickly in the stomach. Findings: During a medication pass observation on June 3, 2025 at 10:28 a.m., Licensed Vocational Nurse (LVN) 1 was observed preparing and administering eight (8) medications, including a tablet of enteric coated aspirin 81 mg (milligram - unit 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-06 · 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 were properly stored and disposed in accordance with the facility's policies and procedures, when a total of three expired medications were found stored in the Medication Refrigerator, the Medication Room, and Medication Cart 1. These failures had the potential to result in the administration of less effective, expired medications, medication errors and compromised treatment outcomes for residents. Findings: 1. On June 3, 2025, at 2:50 p.m., during an inspection of the Medication Refrigerator with Licensed Vocational Nurse (LVN) 2, two bags of expired vancomycin (injectable antibiotic for infection) 750 mg (milligram - unit of measurement) compounded in 250 mL (milliliter - unit of measurement) of NS (normal saline) were observed. The pharmacy label on each bag indicated, Use By: 05/23/2025 (May 23, 2025). In a concurrent interview, LVN 2 verified the directions on the medication labels, indicating the use-by date written as May 23, 2025. LVN 2 stated the medications should have been…

    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 before2025-05-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that high blood sugar level readings above 401 mg/dl (unit of measurement) were reported to the physician in a timely manner as ordered, for one resident reviewed (Resident 1). This failure had potential for delays of treatment for Resident 1 ' s high blood sugar level. Findings: On April 23, 2025, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses that included diabetes (high blood sugars) and hypertension (high blood pressure). The Physician's Order dated, March 15, 2025, indicated, to give, .Humalog Injection (Insulin Lispro - injectable medication to treat high blood sugar)100 UNIT/ML (unit of measurement) . before meals and at bedtime as per following blood sugar sliding scale: - 120-150 (blood sugar reading) mg/dl = 2 units (insulin dose) ; - 151-200 = 3 units; - 201-250 = 8 units; - 251-300 = 10 units; - 301-350 = 12 units; - 351-400= 16 units; and - 401 + = 12 units 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 plan of correction
Show the remaining 13 citations
  • Potential for harm · Dcited before2024-06-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop a care plan to address two of three sampled residents (Residents 1 and 2) episodes of diarrhea. This failure had the potential for facility staff, residents, and family members to be unaware of treatment and services to be provided to Residents 1 and 2's medical condition. Findings: On June 4, 2024, at 9:28 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care and quality-of-life issue. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included displaced intertrochanteric (bony protrusions of the thigh bones) fracture, fracture of right radius (wrist), hypertension (force of the blood against the artery walls) and Type 2 diabetes (body has trouble controlling blood sugar). A review of Resident 1's medical records did not indicate documented care plan addressing episodes of diarrhea. On June 4, 2024, at 10:07 a.m., during an interview…

    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 before2024-06-18 · 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 appropriate infection control practices were implemented for one resident in room [ROOM NUMBER] on isolation precautions. This failure had the potential to result in the spread of infection and cross-contamination that could affect other residents in the facility, visitors, and staff. Findings: On June 4, 2024, at 9:28 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care and quality-of-life issue. On June 4, 2024, at 10:45 a.m., during facility tour observation, room [ROOM NUMBER] did not have a signage for isolation precaution; however, had personal protective equipment (PPE-equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) cart outside the room. On June 4, 2024, at 10:47 a.m., observed Licensed Vocational Nurse (LVN) 1 walked out of the resident's room after doffing the PPE and using the hand sanitizer. On June 4, 2024, at 10:49 a.m., 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-02 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a care plan was developed and implemented for two of three residents reviewed (Residents 142 and 143) when: 1. For Resident 142, a pacemaker (a small device used to control irregular heart beats) was identified on admission and there was no care plan that included the pacemaker information - the manufacturer, type of pacemaker, model and serial number, and the date the pacemaker was implanted. This failure had the potential to place Resident 142 at risk for not receiving immediate care and services in the event of pacemaker malfunction; and 2. For Resident 143, multiple bruising of the upper extremities, left hand bruising, and abrasion of the left knee were identified upon admission, and multiple skin tears identified after admission. There was no person-centered care plan developed and implemented for Resident 143's bruising and multiple skin tears. This failure had the potential to result in Resident 143 not receiving the proper…

    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 · D2024-05-02 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 the care plan was updated and revised when the resident's indwelling urinary catheter (a devise inserted into the bladder held in place by a water-filled balloon which prevents it from falling) was pulled out for one of four residents reviewed (Resident 143). This failure had the potential to place Resident 143 at risk for further trauma when measurable goals and interventions were not formulated to prevent Resident 143 from pulling his indwelling urinary catheter. Findings: During a concurrent observation and interview on April 29, 2024, at 1:05 p.m., with Resident 143, at the Physical Therapy department, Resident 143 was observed performing leg exercises on the stationary bike. Resident 143 stated I don't know what's going on. Resident 143's responsible party (RP) stated Resident 143 had a stroke and currently on blood thinner. She stated Resident 143 had a stroke on the right side of the brain affecting his left side. She 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a skin assessment was completed and documented for one resident reviewed (Resident 11). This failure had a potential for a delay of treatment for Resident 11's left shoulder wound. Findings: During a concurrent observation and interview on April 29, 2024, at 12:42 p.m., with Resident 11, Resident 11 was seen sitting in bed, having lunch. Resident 11 had a foam dressing (dressing - a piece of material such as a pad applied to a wound to promote healing and protect the wound from further harm) on her left shoulder. Resident 11 stated she fell from her bed about two to three weeks ago and hit her left shoulder on the metal foot of the bed. Resident 11 stated she had a deep cut on her left shoulder. Resident 11's record was reviewed. Resident 11 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar) and hypertension (high blood pressure). During a review of Resident 11's Minimum Data Set (MDS…

    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 before2024-05-02 · 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 properly stored and disposed when an expired COVID-19 test (a test used to detect COVID-19 - an infectious disease), was found inside a medication cart, readily available for use. This failure had the potential for the residents to be administered an expired COVID-19 test and could result in an inaccurate test result. Findings: On May 1, 2024, at 2:23 p.m., during a medication cart inspection with Licensed Vocational Nurse (LVN) 1, a box containing a COVID-19 test was observed stored in the medication cart, readily available for use. The test had an expiration date of August 9, 2023. In a concurrent interview, LVN 1 stated the expired test should not have been stored in the medication cart readily available for use and should have been discarded. On May 1, 2024, at 2:38 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the expired COVID test should not have been stored in the medication cart and should have been discarded. On May 1, 2024,…

    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 · D2024-05-02 · 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 the cook followed the directions for preparing egg salad pureed diet for lunch on April 30, 2024. This failure had the potential to compromise the nutritional status for one resident (Resident 20) reviewed for pureed diet. Findings: During a review of the undated facility document titled, Recipe Name: Pureed Salads-Meat/Poultry/Egg/Seafood, the document indicated, .Directions .Remove portions required from regular prepared recipe and place in food processor. Slowly add broth and process until smooth. Use as little broth as necessary to get a smooth product .If needed, add Thickener and process until smooth in consistency .Ensure mixture achieves moist mashed potato or pudding-like consistency . During an observation on April 30, 2024, at 12:12 p.m., with the cook, and the Registered Dietician (RD) present, the cook prepared one portion of pureed egg salad for Resident 20. The cook looked at the recipe for pureed food. The cook started to create a new serving of the pureed egg salad instead of pureeing…

    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 before2024-01-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to reposition one of three sampled residents (Resident 2) every 2 hours per facility policy and procedure. This failure had the potential to result in Resident 2 ' s resolved pressure injury to reoccur. Findings: A review of Resident 2 ' s admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included infection of the skin, cancer of head, face, and neck, and gastrostomy tube. The record indicated the resident was her own responsible party. A review of Resident 2 ' s Brief Interview for Mental Status (BIMS) dated December 12, 2023, indicated the resident had a score of 12 (minimal cognitive impairment). On December 18, 2023, at 11:15 a.m., during an observation of Resident 2, the resident noted to be asleep on an air mattress with head of bed elevated on her back. On December 18, 2023, at 11:48 a.m., during an interview with Certified Nursing Assistant (CNA1), she stated she has Resident 2 in her…

    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 · D2024-01-19 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not maintain medical records that were complete and accurate for one of three sampled residents (Resident 1). This failure had the potential to lead to important clinical information not being properly communicated for Resident 1 with the potential for negative clinical outcomes. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses that included right sided hemiplegia (weakness), cerebral infarction (lack of oxygen to the brain), gastrostomy (opening to the stomach through abdomen), and dysphagia (difficulty swallowing). The record further indicated the resident was discharged to the hospital on November 29, 2023. A review of Resident 1's physician orders indicated orders for the following: a. Medication flushes 30 ml (milliliters- a unit of measure) before administration and 30 ml after administration. 5 ml in between each medication dated November 24, 2023; b. Water flushes 45…

    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 · D2023-08-10 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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-up on the status of an outside podiatry consultation referral for one of three sampled residents. (Resident 1). Resident 1 had requested for an outside podiatry consultation related to a nail fungus concern. This failure had the potential to result in delayed provision of treatment which could negatively affect the resident's well-being. Findings: On June 26, 2023, an unannounced visit was made to the facility to investigate a quality-of-care issue. A review of Resident 1's medical records, indicated the resident was admitted to the facility on [DATE], with diagnoses which included of Parkinson's disease (disorder which causes unintended, uncontrollable movements); spondylosis (painful condition involving the deterioration of the spine); and muscle weakness. A review of Resident 1's Brief Mental Assessment Score (BIMS-a tool to assess cognition) indicated a score of 15, which meant the resident is cognitively intact. A review of Resident 1's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-03 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary services as ordered by the physician, for one resident reviewed for activities of daily living (Resident 7), when it did not evaluate and treat Resident 7 for Physical Therapy (PT) and Occupational Therapy (OT). This failure had the potential to result in Resident 7's difficulty in attaining and maintaining her highest practicable level of physical, mental, functional, and psycho-social well-being. Findings: On January 30, 2023, at 1:06 p.m., an observation and concurrent interview was conducted with Resident 7. Resident 7 was observed in bed, alert and oriented. Resident 7 stated she was admitted to the facility in October 2022, following left hip fracture. Resident 7 stated she wanted to improve on activities of daily living, such as ambulating. Resident 7 stated she did not receive PT, OT, or RNA (Restorative Nursing Assistant) treatments since her admission at the facility. On February 1, 2023, at 1:12 p.m., 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-03 · 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 remove expired Intravenous (IV)-(injection of a medication into a vein and directly into a bloodstream) supplies from the IV cart. This failure had the potential for the staff to use expired IV supplies on residents requiring IV therapy. Findings: During an observation of the IV cart with the Director of Staff Development (DSD) on [DATE], at 2:45 p.m., the following expired items were found readily available for patient use: 1. Three packets of Aplicare Alcohol Swab sticks (helps reduce bacteria that can cause skin infections), had an expiration date of [DATE]; 2. One IV Start Kit had an expiration date of [DATE]; and 3. One IV Administration Set had an expiration date of [DATE]. On [DATE], at 2:47 p.m., an interview was conducted with the DSD. The DSD confirmed that the IV supplies in the IV cart were expired. On [DATE], at 2:55 p.m., an interview was conducted with the Registered Nurse (RN). The RN confirmed that the IV supplies were…

    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 before2023-02-03 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 storage, and cleanliness of the kitchen were in accordance with professional standards for food service safety when: 1. One Ziploc plastic bag containing approximately one and a half pound of tater tots was not dated to show when it has to be discarded or used by; and 2. Six ventilator fans in the kitchen were covered with black debris. These failures had the potential to result in cross contamination and food borne illness in a medically vulnerable population of 26 residents who consumed food from the kitchen. Findings: 1. On January 30, 2023, at 12:51 p.m., an observation of the facility kitchen and concurrent interview were conducted with the Dietary Manager. Two ventilator fans were located at the exit door of the kitchen. One ventilator fan was observed with black debris. The other ventilator fan, located above the exit door of the kitchen, was covered with thick grayish debris. The DM acknowledged the ventilator fan above the exit door of the kitchen was filled with grayish debris. 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

“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 ASPEN SKILLED HEALTHCARE — 35 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 53.7+1.3 vs chain
Health inspection 4 of 53.1+0.9 vs chain
Staffing 3 of 53.9-0.9 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 34 homes this chain runs (chain average 3.7★, per CMS)
1 of 5Kei-Ai Los Angeles Healthcare CenterLos Angeles, CA 2 of 5Berkley East Healthcare CenterSanta Monica, CA 2 of 5Bixby Towers Post-Acute RehabLong Beach, CA 2 of 5Ocean Pointe Healthcare CenterSanta Monica, CA 2 of 5Woodland Post-AcuteWoodland, CA 3 of 5Berkley Post-AcuteVan Nuys, CA 3 of 5Berkley West Healthcare CenterSanta Monica, CA 3 of 5Kei-Ai South Bay Healthcare CenterGardena, CA 3 of 5Lake Park Healthcare CenterOakland, CA 3 of 5Marina Pointe Healthcare & SubacuteCulver City, CA 3 of 5Mission Palms Healthcare CenterWestminster, CA 3 of 5Riverwood Health CareStockton, CA 3 of 5Sierra Vista HealthcareFresno, CA 3 of 5The Gardens Healthcare CenterNorthridge, CA 3 of 5Tracy Nursing And Rehabilitation CenterTracy, CA 4 of 5Alta Healthcare Center of CamarilloCamarillo, CA 4 of 5Country Crest Post-AcuteOroville, CA 4 of 5Lodi Nursing & RehabilitationLodi, CA 4 of 5North Park Post-AcuteTracy, CA 4 of 5San Juan Hills Healthcare CenterSan Juan Capistrano, CA 4 of 5South Marin Health & Wellness CenterGreenbrae, CA 4 of 5The Rehabilitation Center At The PalazzoPhoenix, AZ 4 of 5Villa Valencia Healthcare CenterLaguna Hills, CA 5 of 5Cottonwood Healthcare CenterWoodland, CA 5 of 5Greenridge Post AcuteEl Sobrante, CA 5 of 5Hillcrest Heights Healthcare CenterSan Diego, CA 5 of 5La Casa Via Transitional Care CenterWalnut Creek, CA 5 of 5Oakland Heights Nursing And RehabilitationOakland, CA 5 of 5Pacific Heights Transitional Care CenterSan Francisco, CA 5 of 5Petaluma Post-Acute RehabilitationPetaluma, CA 5 of 5Stonebrook Health And RehabilitationLos Gatos, CA 5 of 5The Avenues Transitional Care CenterSan Francisco, CA 5 of 5University Post-Acute RehabSacramento, CA 5 of 5Woodlands Healthcare CenterLos Gatos, CA

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
APDC, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 11/16/2023
BRADSHAW, PETERIndividualINDIRECT OWNERSHIP INTERESTsince 11/16/2023
ELSNER, ERICIndividualINDIRECT OWNERSHIP INTERESTsince 11/16/2023
KIRKWOOD, JAREDIndividualINDIRECT OWNERSHIP INTERESTsince 11/16/2023
ORGILL, CRAIGIndividualINDIRECT OWNERSHIP INTERESTsince 11/16/2023
PARTI, RAJESHIndividualINDIRECT OWNERSHIP INTERESTsince 11/16/2023
PARTI, SHRUTYIndividualINDIRECT OWNERSHIP INTERESTsince 11/16/2023
PAXMAN, MARCUSIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/16/2023
CASLMON, TIMOTHYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/16/2023
THOMPSON, STEPHENIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/16/2023
GARIBAY, MERCEDESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/29/2024
GUERRA, MONICAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/16/2023
THAKUR, CHAHATIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/16/2023
BRADSHAW, JEFFREYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 06/08/2026
ASPEN HEALTHCARE SERVICES LLCOrganizationADP OF THE SNFsince 11/16/2023
EAST WEST BANKOrganizationADP OF THE SNFsince 11/16/2023
EPC TREVI LLCOrganizationADP OF THE SNFsince 12/01/2021
JACARANDA HEALTHCARE GROUP LLCOrganizationADP OF THE SNFsince 11/16/2023
MOSS ADAMS LLPOrganizationADP OF THE SNFsince 11/16/2023
WELLS FARGO BANK, NATIONAL ASSOCIATIONOrganizationADP OF THE SNFsince 11/16/2023
WELLTOWER OP, LLCOrganizationADP OF THE SNFsince 12/01/2021
BRADY, VERNIndividualADP OF THE SNFsince 11/16/2023
CASE, RYANIndividualADP OF THE SNFsince 11/16/2023
JURADO, FRANKIndividualADP OF THE SNFsince 01/01/2023

CMS files one row per role, so the 35 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$3.5M
Net patient revenuemost recent cost report
-32.5%
Operating marginrevenue minus expenses
$380K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 4%Medicare 6%Other / private 90%

This home reported $380K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$220per resident / day
operating cost
$6,679per month
≈ monthly operating cost
$166per 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 555226. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-06, 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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