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Desert Regional Medical Center D/P SNF

1150 North Indian Canyon Drive, Palm Springs, CA 92262 · For profit - Corporation · 32 certified beds · (760) 323-6511 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jan 20241 immediate-jeopardy citation$14,043 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

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)
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (16% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,043 in federal fines (most recent 2024-02-29)

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1100 N Palm Canyon Dr, 208 208 · (833) 574-2273 · Call to confirm hours
Pharmacy
1100 N Palm Canyon Dr Ste 204 · (866) 206-2983 · Call to confirm hours
Grocery
725 N Palm Canyon Dr · (760) 534-1139 · Call to confirm hours
Park
1100 N Palm Canyon Dr · Typically dawn to dusk
Place of worship

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 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 medication1.4%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine97.7%93.2%79.4%better
Short-stay residents rehospitalized after admission19.4%23.0%22.6%better
Short-stay residents with an outpatient ER visit9.8%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.

71.1% 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 184 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

71.1%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
42.4%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 42.4% 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 132 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 0.37 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 35% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF71.1%CMS range 64.2–77.151.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.5–14.410.7%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 discharge42.4%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 discharge49.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge28.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.4%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 setting86.7%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 discharge83.9%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 worsened0.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 3.4–10.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.711.02Oct 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

5.26
RN hours/ resident / day
1.23
LPN hours/ resident / day
1.61
Aide hours/ resident / day
8.10
Total nurse hours/ resident / day
3.82
RN hoursweekends
15.8%
Total nursing turnover
13.6%
RN turnover

How full it usually is: this home is certified for 32 beds and averages 18.8 residents a day — about 59% occupied, or roughly 13 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 8.10 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 5.26 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.61 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 6.61 hrs/resident/day on weekends vs 8.69 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 5.83 to 3.82 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 16% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

4
deficiencies at the latest standard inspection (2026-06-11)
8
at the previous standard inspection (2025-08-21)

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.

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

  • Immediate jeopardy · Lcited before2024-02-29 · 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 store, prepare, and serve food in a sanitary manner, in accordance with professional standards for food service safety, as evidenced by: 1. Rodent droppings and evidence of nesting (collection of clutter, trash, and debris) was found in the cooking line area of the kitchen, as well as an accumulation of grease and black grime and food, this had the potential to transmit disease to patients by contaminating food and food contact surfaces. In addition, a convection oven (oven that has fans to circulate air around food), a steamer, three ovens, one fryer and a broiler had an accumulation of grease and food grime build-up. This had the potential to attract pests and for microorganism (a microscopic organism, especially a bacterium, virus, or fungus) growth that could be inadvertently transferred to food. 2. The industrial stand mixer had crusted dry substances on the protection grate, the steam jacketed kettles had crusted yellow food inside the kettle, and the convection oven had black and yellow grime build-up…

    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 before2026-06-11 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure food was served at temperatures and with palatability consistent with resident preferences for four of 21 residents reviewed for food service (Residents 11, 18, 39, and 40).This failure resulted in residents receiving meals that were not served at expected temperatures and had the potential to diminish resident satisfaction with meals and adversely affect residents' enjoyment of dining and food intake.Findings: On June 8, 2026, at 10:08 a.m., an interview was conducted with Resident 11 in his room. Resident 11 stated the food was bland. On June 8, 2026, at 11:38 a.m., an interview was conducted with Resident 18 in his room. Resident 18 stated the chicken was bland and most meals were served cold. On June 9, 2026, at 9:12 a.m., an interview was conducted with Resident 39 in his room. Resident 39 stated the food needed to be warmer when it arrived. On June 9, 2026, at 9:21 a.m., an interview was conducted with Resident 40 in her room. Resident 40 stated all meals were lukewarm. On June 10, 2026, at 11:48 a.m. a test…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-11 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician when blood glucose (sugar) levels were below 70 mg/dL (milligram per deciliter) as ordered by the physician, for two of three residents reviewed for notification of change (Residents 36 and 39). This failure had the potential to delay physician evaluation, treatment, and modification of medical interventions related to hypoglycemia (a blood sugar level below normal). Findings: 1. Resident 36's record was reviewed. Resident 36 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar level). The care plan titled, Unstable Blood Glucose, dated June 6, 2026, indicated, .Diabetes Mellitus.blood glucose will be managed as per physicians' orders.interventions.report to physician any hypoglycemic reactions for intervention. The physician's order dated June 7, 2026, indicated, .Humalog (type of insulin) sliding scale (a numerical scale for administration of insulin).rapid acting for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-11 · 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 person-centered baseline care plan for one of three residents reviewed for unnecessary medications (Resident 39) when interventions related to anticoagulation therapy were not included in the resident's baseline care plan. This failure had the potential to result in staff not consistently implementing and monitoring interventions related to anticoagulation therapy (treatment with blood-thinning medication), including monitoring for adverse effects and changes in the resident's condition. Findings:A review of Resident 39's record was conducted. Resident 39 was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (abnormal heart rhythm).The physician's order dated June 7, 2026, indicated, .apixaban (a blood thinner used to reduce the risk of blood clots and stroke in residents with atrial fibrillation) .Indication.atrial fibrillation.A review of Resident 39's baseline care plan indicated there were no care plan…

    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 · D2026-06-11 · 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 physician ordered hypoglycemia management (treatment for low blood glucose [blood sugar]) was implemented and documented for two of three residents reviewed for diabetic management (Residents 36 and 39). This failure had the potential to result in inadequate management of hypoglycemic episodes (an episode of low blood glucose) and negatively affect residents' health and well-being. Findings: 1. Resident 36's record was reviewed. Resident 36 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar level). The care plan titled, Unstable Blood Glucose, dated June 6, 2026, indicated, .Diabetes Mellitus.blood glucose (sugar) will be managed as per physicians' orders.interventions.report to physician any hypoglycemic reactions for intervention. The physician's order dated June 7, 2026, indicated, .Humalog (type of insulin) sliding scale (a numerical scale for administration of insulin) .rapid acting…

    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 before2025-08-21 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. One bag containing a yellow and orange colored liquid was stored in the walk-in refrigerator unlabeled and undated. 2. One package of small, round and brown dessert item was stored in the portable walk-in freezer unlabeled and undated. 3. One sandwich was stored in the resident's refrigerator inside the nourishment room unlabeled, undated, and readily available for use. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 23 residents who receive food in the facility. Findings: 1. On August 18, 2025, at 10:15 a.m., a concurrent observation and interview was conducted with the Dietary Services Supervisor (DSS) in the walk-in refrigerator. A bag with yellow and orange liquid was observed unlabeled and undated. The DSS stated the bag contained liquid eggs which usually came in two bags in a box and further stated, the bag…

    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 · F2025-08-21 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when multiple debris items were found on the ground outside of the designated container and not stored in the appropriate container. This failure had the potential to attract pests and cause infection control issues.Findings:On August 18, 2025, at 11:05 a.m., during a concurrent observation and interview with the Dietary Services Supervisor (DSS), in front of the dumpster storage area, multiple debris items including, wood scraps, pallets, and cardboard were observed on the ground and surrounding area. The DSS stated there should not be any debris, wood scraps, pallets, or carboard on the ground and around the dumpster compactor machine. The DSS stated these items could attract pests and could cause infection control issues.On August 20, 2025, at 12:15 p.m., during an interview with the Registered Dietitian (RD), the RD stated the dumpster compactor machine area should be kept clean and inspected daily to ensure no garbage, wood scraps, or cardboard boxes were left on 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 · E2025-08-21 · tag F0578 — failed to honor advance directives / code status — pattern
    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 ensure for six of 11 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 1, 5, 10, 29, 32 and 39) that: 1. Resident 5's AD was accessible in the resident's chart; and2. The facility followed up with Residents 1, 20, 29, 32 and 39 and/or Resident Representative (RP) regarding formulation of an AD.This failure had the potential to result in the ADs for Residents 1, 5, 10, 29, 32 and 39 not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored. Findings: 1. On August 19, 2025, at 10:05 a.m., an interview was conducted with Resident 5. Resident 5 stated he could not recall if he had been given information about ADs and would like more information. A review of Resident 5's admission Facesheet indicated Resident 5 was admitted to the facility on [DATE]. A review of Resident 5'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-21 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician's orders for fluid restriction were followed for two of two residents (Residents 29 and 40) reviewed for nutrition and hydration.These failures had the potential to:1. cause further electrolyte (minerals that help with water balance in the body) imbalance for Resident 29, and2. exacerbate heart failure for Resident 40.Findings: 1.A review of Resident 29's admission Facesheet, indicated Resident 29 was admitted on [DATE], with diagnoses which included acute kidney injury and hyponatremia (low salt levels in the body). A review of Resident 29's Minimum Data set (MDS - and assessment tool) dated July 23, 2025, indicated Resident 29 had a Brief Interview for Mental Status (BIMS - designed to quickly evaluate a resident's cognitive function) use score of 15 (cognitively intact). A review of Resident 29's Orders indicated restrict fluids, 1200 ml (unit of measurement) per 24 hours with order date of July 23, 2025. A review of Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-21 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices were implemented to meet the needs of the residents when: 1. One nurse was observed to not use the pill cutter to cut a medication tablet in half and instead, by hand to prepare and administer for one of four residents (Resident 10) 2. One nurse was observed to leave the resident's room before the resident finished one medication solution for one of four residents (Resident 42) 3. One blood pressure medication with hold parameters was administered not in accordance with the physician order and without clarification of the order for one of five residents reviewed (Resident 32) These failures had the potential for residents to receive inadequate medication therapy.1. On August 19, 2025, at 8:10 a.m., during a medication pass observation with RN 5, it was noted RN 5 prepared one of Resident 10's medication, citalopram (medication to treat mood disorder) 20 mg (milligram - 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-21 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 food with appetizing taste according to residents' preferences for four of 23 sampled residents (Residents 10, 23, 40, and 41). This failure had the potential to decrease the nutritional intake and negatively affect the nutrition status of Residents 10, 23, 40 and 41. Findings: On August 18, 2025, the following interviews were conducted: - At 1:26 p.m., Resident 41 stated, chicken is like leather. - At 1:36 p.m., Resident 40 stated, chicken is dry and tough to chew. - At 1:40 p.m., Resident 10 stated, food not good, meat entrees taste dry and rubbery. - At 3:31 p.m., Resident 23 stated, food is hit miss, no taste, mushy texture. On August 20, 2025, at 12:15 p.m., during a concurrent observation and interview with the Registered Dietitian (RD), a test tray (to evaluate the quality of a meal during a meal service and identify any areas for improvement) of pork loin (pureed diet) and baked chicken (regular diet) was evaluated during meal service. The chicken was observed to be bland, dry and with gritty…

    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
Show the remaining 11 citations
  • Potential for harm · D2025-08-21 · 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

    Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan to address a physician-ordered fluid restriction for one of one resident (Resident 40) reviewed.This failure resulted in Resident 40's fluid restriction not being incorporated into the plan of care, which had the potential to exacerbate resident's congestive heart failure (a condition which causes fluid buildup in the body) and compromise his overall health status. Findings:On August 19, 2025 at 8:45 a.m., an observation was conducted outside of Resident 40's room. A sign indicating a fluid restriction of 1500 milliliters (ml) was posted on the wall. On August 19, 2025 at 8:46 a.m., an interview was conducted with Resident 40. Resident 40 stated he was placed on fluid restriction due to difficulty breathing. A review of Resident 40's admission Facesheet indicated an admission date of August 14, 2025. A review of Resident 40's History and Physical, dated August 16, 2025, indicated an assessment of systolic congested heart failure. A review of Resident 40's Active 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to follow its policy and procedure for the two-step tuberculosis (TB - an infectious disease which affects the lungs or other parts of the body) screening, a requirement for the annual health examinations, for two of eight staff members reviewed.This failure had the potential to place staff and vulnerable residents at risk for exposure to infection.Findings:On August 21, 2025, the facility's employee files were reviewed. Two employee files indicated the following: 1. Certified Nurse Assistant 4 (CNA 4) - No documentation was found indicating the annual tuberculosis screening was completed in 2022.2. Registered Nurse 2 (RN 2) - No documentation was found indicating the annual tuberculosis screening was completed in 2024.On August 21, 2025, at 10:20 a.m., a concurrent interview and record review was conducted with the Senior Human Resources Generalist (SHRG). The SHRG stated these two staff members did not complete their annual tuberculosis screenings timely. The SHRG stated there was no email communication for CNA 4 in 2022 or…

    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 before2025-01-14 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident ' s representative, of a transfer to the Emergency Department (ED) for further evaluation of agitation for one of three residents (Resident 1). This failure resulted in Resident 1 ' s Representative not being informed of the transfer to the ED, limiting their ability to participate in the resident's medical care decisions to the extent deemed possible. Findings: On January 9, 2025, an unannounced visit was made to the facility for a quality of care issue. A review of Resident 1 ' s, Face Sheet, undated, indicated, resident was admitted to the facility on [DATE], with an admitting diagnosis of a resistive organism fungemia (fungal infection in the blood). On January 9, 2024, at 3:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, the document, Appointment of Personal Representative (APR), is part of the admission packet. The DON verified, this document allowed the resident to appoint a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to ensure dementia (memory loss) training was provided to one of two sampled employees (CNA1). This failure had the potential to result in staff lacking the necessary skills to manage and care for residents with dementia effectively. Findings: On August 1, 2024, at 9:30 a.m., an unannounced visit was conducted to investigate an allegation of abuse. The personnel file for Certified Nursing Assistant (CNA) 1, who was hired in January 29, 2024, was reviewed. There was no documentation showing that CNA 1 had received dementia training. On August 1, 2024, at 12:38 p.m., a concurrent interview and review of CNA 1's personnel file were conducted with the Regulatory Manager (RM). The RM stated, CNAs are provided training for dementia annually. The RM stated, CNA 1 had not undergone this training. The RM stated, all CNAs should have dementia training for safety and to ensure they know how to care for and handle residents with dementia. On August 1, 2024, at 12:45 p.m., the Assistant Director of Nursing (ADON) was interviewed. 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-29 · tag F0803 — failed to meet residents' dietary needs — widespread
    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 lunch menu served on February 27, 2024, met the nutritional need of 15 out of 16 residents in accordance with established national guidelines. This failure had the potential for residents not to receive the caloric intake needed, when the established menu was not followed, which could result in poor nutrition and further compromise the residents' medical status. Findings: An observation and concurrent interview were conducted on February 26, 2024, at 12:20 p.m., with Resident 227. Resident 227 stated, he should receive double-portions, and only received one scoop of potatoes today. Resident 227 stated, sometimes the facility messed up the order and he had to wait 45 minutes for the missing food. Resident 227 further stated, how was he supposed to gain weight if the facility kept messing up his food orders. An observation, on February 27, 2024, at 11:30 a.m., was conducted during the tray line. The Associate Patient Dining Staff (APDS) was portioning out food into each resident's styrofoam…

    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 · F2024-02-29 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 maintain an effective pest control program to keep the facility free of pests and rodents when: 1. There were rodent droppings and evidence of nesting found in the cooking line; 2. There was not a set schedule for the pest control company to service the kitchen; and 3. Recommendations made by the pest control company were never implemented. These failures created an environment attracting rodents and the potential contamination of food and kitchen equipment used to supply meals to 15 out of 16 vulnerable residents, who are put at risk for food-borne illness (caused by food contaminated with bacteria, viruses, parasites, and toxins). Findings: During the initial tour of the kitchen on February 26, 2024, at 11:35 a.m., at the cooking line where food was prepared for the residents, there were rodent droppings and evidence of nesting (collection of clutter, trash, and debris) identified inside a compartment between the stove and the fryer.…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-29 · 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, for two employees observed, to ensure infection control policy and procedures for hand hygiene and personal protective equipment (PPE) were implemented when: 1. RN 2 did not perform hand hygiene before donning gloves on two occasions. In addition, RN 2 did not remove gloves after direct patient care and exited the room to enter another resident's room. 2. One Certified Nursing Assistant (CNA 1) did not perform hand hygiene upon entering and exiting a resident's room and after providing direct patient care. These failures had the potential to spread infection and compromise the overall health of residents residing in the facility. Findings: 1. During an observation on February 26, 2024, at 12:30 p.m., in Resident 74's room, RN 2 did not change gloves between providing care for two residents. In addition, RN 2 was observed to answer the telephone with the same gloved hands and entered Resident 77's room without performing hand hygiene. RN 2 entered the hallway and was observed to remove gloves without performing…

    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 · E2024-02-29 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain essential kitchen equipment in a safe operating condition, as evidenced by multiple pieces of equipment out of service and not being clean or maintained. These failures led to harborage conditions in the kitchen that was attracting pest and the potential for cross contamination and foodborne illness in 15 out of 16 medically compromised residents who received food from the kitchen. Findings: During an observation in the bulk food preparation area and concurrent interview with the Executive Chef (Chef), on February 26, 2024, at 11:22 a.m., the double convection oven (oven that has fans to circulate air around food) had rust on the side and the inside had a build-up of food and yellow grime. The Chef stated, that they only have one working oven in the kitchen, all the other ovens are not working, because of the large volume of meals they prepare they do not have time to clean it. During a concurrent observation and interview with the Chef on February 26, 2024, at 11:35 a.m., at the cooking line where…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the pharmacist recommendation to reduce the number of anticoagulants (medications to reduce or prevent blood from clotting) from two medications to single medication was acted upon by providing a rationale for not reducing the number of anticoagulants (medications that reduce or prevent blood from clotting), for one of five residents reviewed for unnecessary medications (Resident 76). This failure had the potential to result in adverse consequences related to anticoagulant therapy. Findings: During a review of the facility document titled Consultant Pharmacist's Recommendation to Inter-Disciplinary Team (IDT), dated February 25, 2024, indicated, .The resident has orders for Eliquis (Apixaban- anticoagulant) and Aspirin (anticoagulant) .Would monotherapy (single medication to treat a condition) be clinically feasible? . A review of Resident 76's record indicated Resident 76 was admitted to the facility on [DATE], with diagnoses which included…

    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 · D2024-02-29 · 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 interview and record review, the facility failed to designate a person to serve as the Director of Food and Nutrition Services (DFANS), who meets the State requirements for food service managers or dietary managers. This failure resulted in a lack of oversight in the kitchen which led to unsanitary conditions being present and an Immediate Jeopardy being called because of the presence of evidence of pests (cross reference F812). This facility failure had the potential to affect 15 out of 16 medically compromised residents who receive food from the kitchen. Findings: During an interview on February 26, 2024, at 10:02 a.m., the Clinical Nutrition Manager (CNM) stated, she is a Registered Dietician and the full-time qualified staff member over the kitchen. The Director of Food and Nutrition Services (DFNS) who was also serving as the Environmental Services Director stated, he was not a qualified food service manager. The Executive Chef (Chef) was also present and stated he was not a qualified food service manager and is in the process of becoming a Certified Dietary Manager…

    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 · D2024-01-03 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of verbal abuse within 2 hours to California Department of Public Health (CDPH) after the allegation was made, for one of four residents reviewed (Resident 1). This failure had potential to result in further abuse for Resident 1, affecting the resident's physical, emotional, and psychosocial well-being. Findings: On December 6, 2023, at 10:53 a.m., CDPH received a fax (facsimile - telephonic transmission of scanned-in printed material) report of an allegation of abuse involving a Certified Nurse Assistant (CNA), a License Vocational Nurse (LVN) and a resident. On December 13, 2023, at 9:20 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included blunt head trauma (head injury resulting from contact between the head and another object). A review of Resident 1's History 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.

    Freedom from Abuse, Neglect, and Exploitation 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

$14,043 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $14,043 — penalty dated 2024-02-29
  • Medicare payment denial — starting 2024-03-29 for 14 days

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.

Who owns this facility

Owner / managerTypeRoleSince
TENET CALIFORNIA INCOrganizationDIRECT OWNERSHIP INTERESTsince 10/05/2009
HEALTH SERVICES NETWORK HOSPITALS, INC.OrganizationINDIRECT OWNERSHIP INTERESTsince 10/14/2014
TENET HEALTHCARE CORPORATIONOrganizationINDIRECT OWNERSHIP INTERESTsince 10/05/2009
SMITH, SHARILEEIndividualCORPORATE DIRECTORsince 03/01/2024
BURKETT, JOSHUAIndividualCORPORATE OFFICERsince 10/20/2024
DITORO, MICHAELIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/06/2025
MACK, KRISTINAIndividualCORPORATE OFFICERsince 07/24/2008
PAGANO, ANGELOIndividualCORPORATE OFFICERsince 07/01/2024
GULLE, APOLLO LESTERIndividualADP OF THE SNFsince 10/15/2025

CMS files one row per role, so the 11 rows in the source record cover these 9 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.

3 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.

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 555417. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-11, 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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