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Webster House

437 Webster Street, Palo Alto, CA 94301 · Non profit - Corporation · 145 certified beds · (650) 328-3300 Medicare & Medicaid certified

Call the home — (650) 328-3300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (21% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Urgent care / clinic
Stride0.2 mi
512 Hamilton Ave · (650) 323-2200 · Call to confirm hours
Pharmacy
421 Kipling St · (650) 391-9740 · Call to confirm hours
Grocery
Noodelist0.3 mi
470 Ramona St · (408) 464-2988 · Call to confirm hours
Park
200 Kipling St · (650) 496-6962 · 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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.

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

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 increased10.1%10.2%15.4%better
Long-stay residents who lose too much weight5.7%4.0%5.4%typical
Long-stay residents with a catheter left in their bladder1.5%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.6%1.2%2.0%better
Long-stay residents with depressive symptoms0.6%7.3%6.5%better
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 injury2.2%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened12.9%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication4.8%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers1.9%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control23.0%10.2%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table8.1%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine92.5%93.2%79.4%better
Short-stay residents rehospitalized after admission27.4%23.0%22.6%worse
Short-stay residents with an outpatient ER visit4.3%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days4.032.251.67worse
Long-stay outpatient ER visits per 1,000 resident days1.581.571.80better

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.

62.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 156 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.0%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
45.5%U.S. median 56.6%
Met the expected recovery
0.34U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 45.5% 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 88 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 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.0%CMS range 54.7–69.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 7.1–14.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge45.5%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 discharge52.3%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 discharge38.6%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 identified99.3%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 setting85.9%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 discharge95.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or 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 hospitalization5.4%CMS range 3.3–9.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.06
RN hours/ resident / day
1.23
LPN hours/ resident / day
2.76
Aide hours/ resident / day
5.05
Total nurse hours/ resident / day
0.76
RN hoursweekends
20.6%
Total nursing turnover
36.4%
RN turnover

How full it usually is: this home is certified for 145 beds and averages 63.7 residents a day — about 44% occupied, or roughly 81 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 5.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.06 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.76 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 3.79 hrs/resident/day on weekends vs 5.56 on weekdays — 32% thinner on weekends — a notable drop. RN hours go from 1.18 to 0.76 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 21% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

2
deficiencies at the latest standard inspection (2025-01-30)
15
at the previous standard inspection (2023-02-27)

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Ecited before2026-06-09 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide services according to professional standards for one of three residents (Resident 1) when there was no documentation of medication administration for Resident 1's scheduled medications and nutritional supplements, five to six days on day shifts and one to two days on evening shifts in November 2025.These failures had the potential to affect Resident 1's health, safety and well-being.Findings:Review of Resident 1's face sheet (summary page of a patient's important information) indicated Resident 1 was admitted to the facility with diagnoses including dementia (a condition with group of symptoms affecting thinking and social abilities interfering with daily functioning), respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body organs are low), dry eye syndrome of bilateral lacrimal glands (when the tear-producing glands located above both eyes failed to produce enough watery tears), and post-menopausal atrophic vaginitis…

    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 before2025-01-30 · 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, record review, and facility policy review, the facility failed to ensure medications were properly stored for 1 (Resident #31) of 6 residents observed for medication administration. Findings included: A facility policy titled, Storage of Medication, dated 01/2024, indicated, The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. An admission Record revealed the facility admitted Resident #31 on 09/29/2017. According to the admission Record, the resident had a medical history that included diagnoses of essential hypertension and hemiplegia and hemiparesis following cerebral infarction. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. During medication administration observation on 01/28/2025 at 8:35 AM, Licensed Vocational Nurse (LVN) #2 left medication that belonged to…

    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 before2025-01-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene and wore gloves during eye drop administration for 1 (Resident #35) of 6 residents observed for medication administration. Findings included: A facility policy titled, Infection Prevention & Control Program, revised 01/2024, indicated, Treat all human blood, bodily fluids and other potentially infectious materials as if they are infections. SP [standard precautions] include but are not limited to hand hygiene; use of gloves, gowns, masks, eye protection or face shields when contact with any blood or moist body fluids (secretions and excretions) is likely, room placement; injection and medication safety practices, respiratory hygiene/cough etiquette; environmental cleaning and disinfection; and safe management of textiles and laundry. A policy titled, Medication Administration Eye Drops, dated 01/2023, indicated, Policy To administer ophthalmic solution into eye in a safe and accurate manner. The policy specified, 8. With a gloved finger, gently pull…

    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 · E2023-02-27 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to review the risks and benefits of bed rails (adjustable metal or rigid plastic bars that attach to the bed) with the resident or resident representative and obtain informed consent prior to the use of bed rails for seven of 27 residents (Residents 18, 23, 27, 37, 45, 55, and 363). This failure had the potential to put the residents at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails. Findings: During the initial tour of the facility conducted on 2/21/23, at 9:30 a.m., Residents 18, 23, 37, 45, and 55, all had quarter bed rails elevated. During a concurrent interview and record review on 2/23/23, at 3:38 p.m., with the director of nursing (DON), when asked to show bed rail consents that indicated the facility reviewed the risks and benefits of bed rails with Residents 18, 23, 37, 45 and 55 or their legal representatives, the DON was unable to show the consents for those five residents. She stated the facility recently started to obtain bed rail consents 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-27 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility had a medication error rate of 17.86%, when five medication errors out of 28 opportunities occurred during medication administrations for three of six residents (Residents 11, 24, and 49). These deficient practices resulted in medications not being given in accordance with the prescriber's orders and/or manufacturer's specifications, which could have resulted in the residents not receiving the full therapeutic effects of the medications. Findings: 1. During a medication pass observation on [DATE], at 9:06 a.m., with Registered Nurse A (RN A), he administered six medications to Resident 49, including one tablet of aspirin enteric coated (a pain reliever with a coating that creates a delayed release of the medication, also used to prevent stroke) 81 milligrams (mg, unit of dose measurement). A review of Resident 49's clinical record indicated a physician's order, dated [DATE], for aspirin low dose tablet chewable 81 mg, give 1 tablet by mouth one time…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-27 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure expired medications were removed, and medications were labeled and stored according to manufacturer's instructions for one out of one medication room and two out of two medication carts. These deficient practices had the potential for residents to receive medications with reduced potency and had the potential to result in medication errors. Findings: 1. During an inspection of the third floor medication cart on 2/21/23, at 10:26 a.m., with Registered Nurse A (RN A), a bottle containing loratadine (medication for allergies) 10 milligram (mg, unit of dose measurement) tablets was identified with the expiration date of 1/2023. RN A verified the medication was expired. The medication cart inspection with RN A also identified a bottle of latanoprost 0.005% eye drops (medication used to treat glaucoma) unopened but kept in the medication cart. The pharmacy label on the eye drop indicated to refrigerate until opened. RN A verified this…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-27 · 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 ensure the dietary staff followed their recipe when the senior lead cook (SLC) prepared yellow squash and red pepper vegetables for lunch. This failure had the potential to compromise the nutritional value and palatability of the food for 58 residents who received food services from the facility. Findings: During an interview on 2/21/22 at 10:43 a.m., Resident 363 stated, Food is not so good. He further stated hot food was served cold, and the food was not tasty. During an interview with Resident 10 on 2/21/23 at 11:00 a.m., Resident 10 stated, Food has no taste. During an interview with Resident 46 on 2/21/23 at 11:30 a.m., Resident 46 stated, Food is not tasty, cold, stale, and awful. Resident 46 further stated, Vegetables are not cooked well, not soft enough to eat, shrimp is tough. She further stated she could not even cut shrimp with a dinner knife. During an interview with Resident 34 on 2/21/23 at 11:45 a.m., Resident 34 stated, Food does not taste good. Review of the facility lunch menu on 2/22/23…

    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 before2023-02-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. There was expired food in the kitchen; 2. Prepared food trays in the walk-in refrigerator were uncovered and undated; 3. Wet and dry containers were stored together; 4. The Dish washer (DW) used expired sanitizer test strips to test sanitizer solution; and 5. [NAME] K (CK) failed to perform hand hygiene between tasks. These failures had the potential to result in food borne illness for 58 residents who received food from the kitchen. Findings: 1. During initial kitchen observation and concurrent interview with the assistant director of dining services (ADDS), on 2/21/23 at 9:05 a.m., there was sweet ground white chocolate powder on the dry food storage shelf, with an open date of 8/27/22 and an expiration date of 1/31/23. There was a container of black pepper corns on the spice shelf with an open date of 12/27/21 and an expiration date of 12/27/22. There was a plastic container of croutons on the kitchen counter with an open date of 2/8/23…

    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 · D2023-02-27 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 complete a significant change in status Minimum Data Set (MDS, a comprehensive assessment tool) when one of 15 sampled residents (Resident 35) experienced declines in multiple areas of health status. Failure to comprehensively assess the resident had the potential to compromise the facility's ability to develop and implement resident-centered care plan interventions. Findings: During observations on 2/21/23 at 11:13 a.m., 2/22/23 at 1:30 p.m. and 2/23/23 at 8:46 a.m., Resident 35 was lying in bed. She appeared weak, did not move much while in bed, and was minimally verbal. During a lunch observation on 2/24/23 at 1:08 p.m., Resident 35 was lying in bed with her caregiver at bedside. The caregiver was attempting to feed Resident 35, but the resident would only accept liquids and small bites of mashed banana. When the caregiver tried to offer other foods from the lunch tray, Resident 35 said, No. Review of Resident 35's medical record…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-27 · 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 one of four residents (Resident 60) had hearing aids on while awake for optimal hearing abilities. This failure had the potential to result in ineffective and insufficient communication between Resident 60 and caregivers, and could have negatively affected the resident's psychosocial well-being. Findings: During a concurrent observation and interview, on 2/21/23, at 11:45 a.m., in Resident 60's room, Resident 60 was observed lying in the bed awake without his hearing aids on. The hearing aids were on the nightstand behind his bed. The surveyor asked Resident 60 the same question three times and the resident was not able to answer. He pointed to his ears, stated he could not hear and that he needed the hearing aids. During an interview on 2/21/23, at 12:00 p.m., with registered nurse A (RN A), he stated usually Resident 60's wife came before lunch time, and she put the hearing aids on. During an observation on 2/22/23, at 11:40…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2023-02-27 · 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 ensure necessary services were provided to promote healing of a pressure ulcer (damage to the skin and underlying tissues due to prolonged pressure) for one of two sampled residents (Resident 35) when: 1. There were 8 days for which there was no documentation that Resident 35's pressure ulcer was treated; and 2. Resident 35's pressure ulcer assessment was incomplete. These failures had the potential to result in worsening of Resident 35's pressure ulcer. Findings: Review of Resident 35's medical record indicated she was admitted on [DATE] and had the diagnoses of dementia (mental disorder caused by brain disease or injury), spinal stenosis (narrowing of the spinal canal) osteoporosis (condition that causes bones to become brittle and fragile) and scoliosis (abnormal curvature of the spine). Review of Resident 35's 6/2022 treatment administration record (TAR) indicated she had a stage 3 pressure ulcer (full-thickness tissue loss) on her mid-back. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their fall management program for two of four residents (Residents 56 and 4) when: 1. Fall interventions were not implemented for Resident 56; and 2. No new interventions were developed and implemented after Resident 4 fell. These failures had the potential to result in further falls and/or injury to the residents. Findings: 1. Review of Resident 56's record indicated she was admitted to the facility with diagnoses including dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning) and bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making). Review of Resident 56's IDT Post Event Review, dated 12/22/22, indicated she had a fall on 12/22/22. Review of Resident 56's fall care plan indicated an intervention, initiated on 12/29/22, The resident uses silent alarm. Check for placement and functioning Q [every] shift.…

    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 · D2023-02-27 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive policy for enteral feeding (the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) services, when there was no policy that indicated a consistent method that a licensed nurse should use for bolus feeding (the administration of a limited volume of enteral formula over brief periods of time). This failure had the potential to result in inconsistency of care and complications related to the G-tube and cause harm to the resident. Findings: A review of Resident 22's face sheet (a document that gives a resident's information at a quick glance, including contact details and a brief medical history), indicated the resident was admitted to the facility with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dysphagia (swallowing difficulties). A review of Resident 22's hospital Discharge summary, dated…

    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 · D2023-02-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the controlled substance (drugs with high potential for abuse or addiction) medications were fully accounted for when: 1. A random controlled medication use audit for two out of three residents (Residents 20 and 39) showed that medications were signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications), but were not documented as given to the residents on the medication administration record (MAR); and 2. Expired and discontinued controlled drugs were not removed from the medication cart. These failures had the potential to result in loss, misuse, and/or diversion of controlled medications. Findings: 1. The Controlled Drug Records (CDRs) for three (3) random residents receiving PRN (meaning as needed) controlled medications were requested for review during the survey. During a concurrent interview and record review with the director of nursing (DON) on [DATE] at 1:56…

    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 · D2023-02-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Residents 27) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors). Resident 27 received Abilify (an antipsychotic medication) when there were no specific target behaviors (behaviors intended to be reduced or eliminated by the medication) monitored. There was also no indication that Resident 27's behaviors presented a danger to herself or others, or caused significant distress to the resident. This failure put the resident at risk for experiencing adverse effects from unnecessary psychotropic medications such as dry mouth, blurred vision, urinary retention, constipation, heat intolerance, and tachycardia (abnormally rapid heart rate). Findings: A review of Resident 27's medical record indicated she was admitted to the facility with diagnoses including Alzheimer's disease (a progressive disease that destroys memory 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of ten sampled residents (Resident 24) was free from significant medication errors when she received six doses of expired Insulin Lispro (fast-acting insulin, medication to lower blood sugar level). This deficient practice had the potential for the resident to receive ineffective use of the insulin, resulting in uncontrolled high blood sugar for the resident. Findings: During an observation on [DATE] at 11:31 a.m., at Resident 24's bedside, licensed vocational nurse B (LVN B) was observed pricking Resident 24's left forefinger to obtain a blood sample to measure her blood sugar (BS) level. The BS reading was 402 milligrams/deciLiter (mg/dL, unit of measurement; normal BS is less than 100 mg/dL) at that time. LVN B stated she would come back with some insulin. During a concurrent observation and interview on [DATE], at 11:40 a.m., LVN B withdrew 11 units of insulin lispro 100 units/1 milliliter (unit of dose measurement) into 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0851 — isolated
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) for August of 2022. This deficient practice prevented the provision of complete and accurate direct care staffing information to the public. Findings: Review of the CMS PBJ (payroll-based journal) Staffing Data Report, dated 7/1/22 to 9/30/22, indicated the facility had no registered nurse (RN) hours from 8/1/22 to 8/31/22. The report also indicated for the same time period, the facility did not have licensed nursing coverage 24 hours a day. During an interview with the director of nursing (DON) on 2/24/23 at 2:42 p.m., she stated the information on the PBJ Staffing Data Report was not accurate. The DON stated the senior director of risk management (SDRM) called the facility and explained that he submitted the wrong direct care staffing information to CMS for the month of August 2022. During an interview with the administrator (ADM) on 2/27/23 at 10:17 a.m., he explained that the SDRM made an error when…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to implement infection prevention and control practices when: 1. Certified nurse assistant G (CNA G) did not wear a facemask while providing care to Resident 32; 2. Registered nurse H (RN H) did not perform hand hygiene (hand washing or use of alcohol-based hand rub [ABHR]) when changing gloves; and 3. Licensed vocational nurse B (LVN B) did not disinfect medical equipment before and after using it on Resident 24 These failures had the potential to result in transmission and spread of infection in the facility. Findings: 1. During an observation on 2/27/23 at 8:15 a.m., CNA G was in Resident 32's room setting up her breakfast tray. CNA G's facemask was hanging down from her right ear and was not covering her mouth and nose. While unmasked, CNA G was standing right next to Resident 32 and speaking to her while setting up the breakfast tray. Resident 32 was also not wearing a facemask. During an interview with CNA G on 2/27/23 at 8:20 a.m., she confirmed she did not wear her facemask while setting up Resident 32'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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-11-15 · 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 — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a cook utilized standardized recipes for puree (smooth texture) food preparation to ensure nutritive value. This failure resulted in the residents prescribed puree diet being placed at an increased risk for nutritional impairment. Findings: During a concurrent observation and interview with lead cook (LC) on11/14/19 at 9:53 a.m., LC was adding water inside a container with biscuits inside. LC stated she used water when pureeing biscuits. During a review of recipe with the dietary manager (DM) on 11/14/19 at 10:15 a.m., puree recipe for buttermilk biscuits indicated, blend biscuits with milk in Robocop, blender or food processor until smooth. During an interview with registered dietician A (RD A) on 11/14/19 at 10:22 a.m., RD A confirmed changes in nutrients of the biscuits could occur when diluted with water instead of milk.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-11-15 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions when: 1. Bin used to store flour was unlabeled; 2. Scoop utensil was lying on top of the thickener bin; 3. Ice machine spout was dirty; 4. Staff crossed yellow line (division between kitchen and dining area) during trayline without hairnets; 5. Beef meat loaf was held for service at 140 F (F, fahrenheit, unit of temperature). This failure had the potential for occurrence of food-borne illnesses. Findings: 1. During an observation on 11/12/19 at 8:21 a.m., with the dietary manager (DM), a bin with dry food powder was observed under the kitchen sink. During an interview with the registered dietitian A (RD A) on 11/15/19 at 3:18 p.m., RD A stated the flour should have a label. 2. During an observation on 11/12/19 at 8:23 a.m., there was a scoop lying on top of thickener container. The DM stated it was ok for the scoop to be stored on top of the container. During an interview with RD A on 11/15/19 at 3:18 p.m., the RD A stated the scoop should…

    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 before2019-11-15 · 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, interivew and record review, the facility failed to properly store and label drug and biological's in accordance with facility policy and current standards when: 1. A bottle of Milk of Magnesia (used for constipation) was with altered pharmacy label. 2. An eye antibiotic passed its length of therapy was found in the medication cart. 3. A vial of Humalog (used to regulate insulin in the blood) was expired. 4. Licensed vocational nurse I (LVN I) left Brimonidine 0.2% (used to relieve redness in the eyes caused by minor eye irritations.) on top of the cart unattended. These failures can potentially compromise Residents' health and safety. Findings: 1. A bottle of Milk of Magnesia (used for constipation) was found with altered pharmacy label. During a medication cart audit with licensed vocational nurse G (LVN G) on [DATE] at 10:03 a.m., a bottle of Milk of Magnesia was found with altered pharmacy label. During an interview with the director of nursing (DON) on [DATE] at 7:53 a.m., the DON…

    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 · D2019-11-15 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure a follow up was made in a timely manner for a missing denture for one of two sampled residents (6). Resident 6' s upper denture was missing and Resident 6's insurance denied to replace. These failures caused a delay in Resident 6 receiving the necessary dental services and could negatively affect Resident 6's physical comfort and psychosocial well-being. Findings: Review of Resident 6's clinical record indicated she was admitted to the facility with a diagnoses including hemiplegia (affecting one side of the body) following cerebral infarction (stroke). Review of Resident 6' Progress Notes dated 8/6/19, indicated Resident 6's upper denture was not taken by a family member (FM) and would be evaluated by a dentist for possible replacement. Resident 6 was also seen by the dentist on 8/23/19, and recommendation was to have a full set of dentures (upper and lower). Review of the facility's theft and lost binder indicated Resident 6's full upper dentures was missing on 8/6/19. It also noted, on 10/22/19, Resident 6 was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-11-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff implemented the infection control practices when: 1. Treatment nurse C (TXN C) did not perform hand hygeine while providing wound treatment; 2. Certified nursing assistant D (CNA D) disposed dining ware of a resident in the isolation room; 3. Licensed vocational nurse E (LVN E) failed to perform hand hygeine between different medication routes. These failures had the potential to put vulnerable residents at risk for infection. Findings: 1. During a wound treatment observation with TXN C on 11/14/19 at 12:00 p.m., TXN C performed wound treatment on Resident 24's right lateral foot. TXN C confirmed she wore at least two layers of gloves on each hand while treating Resident 24's wound, removing each layer as she cleaned and dressed the wound. During an interview with the director of staff development (DSD) on 11/15/19 9:17 a.m., he stated using multiple layers of gloves and removing layer by layer during wound treatment should not be done. Licensed nurse need to apply hand hygiene every time they…

    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

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to FRONT PORCH — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 54.8+0.2 vs chain
Health inspection 5 of 54.2+0.8 vs chain
Staffing 5 of 54.9≈ chain avg
Quality measures 5 of 54.8+0.2 vs chain
The other 8 homes this chain runs (chain average 4.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
FRONT PORCH COMMUNITIES AND SERVICESOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 04/01/2022
DURANTEAU, NANCYIndividualCORPORATE DIRECTORsince 04/01/2021
FORTE, VINCENTIndividualCORPORATE DIRECTORsince 04/01/2021
HANDY, JOANNEIndividualCORPORATE DIRECTORsince 04/01/2021
JACOBS, LAURAIndividualCORPORATE DIRECTORsince 01/01/2019
KROEKER, KEVINIndividualCORPORATE DIRECTORsince 01/01/2018
MCGOVERN, MARIONIndividualCORPORATE DIRECTORsince 01/01/2017
SPENCER, PETERIndividualCORPORATE DIRECTORsince 01/01/2026
TONNU, DIEMLANIndividualCORPORATE DIRECTORsince 01/01/2018
WESSON, OLIVERIndividualCORPORATE DIRECTORsince 01/01/2017
WHITTAKER, SUSANIndividualCORPORATE DIRECTORsince 01/23/2018
KELLY, SEANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 03/06/2023
SALVADOR, EDUARDOIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
VRANICH, RACHELIndividualCORPORATE OFFICERsince 06/17/2022
AKOPYAN, GEVORKIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/12/2022
DUNN, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2026
FREDERICK, MELISSAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2017
ICHIEN, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/04/2018
JORDAN, MARIAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/19/2024
MACANGO, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/04/2026
MCMULLIN, MARYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
OLSON, KARIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
MERKIN, NICKOLASIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 11/12/2025
NELSON, HARRYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 11/12/2025
PENNINGTON, PAIGEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 11/12/2025

CMS files one row per role, so the 30 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$10.2M
Net patient revenuemost recent cost report
-74.8%
Operating marginrevenue minus expenses
$615K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 13%Other / private 16%

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $615K 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$836per resident / day
operating cost
$25,408per month
≈ monthly operating cost
$478per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA

Paying with Medicaid

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 555156. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-30, 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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