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Centinela Grand INC

2225 North Perris Boulevard, Perris, CA 92571 · For profit - Corporation · 109 certified beds · (951) 657-2135 Medicare & Medicaid certified

Call the home — (951) 657-2135 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jun 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (12% 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 citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
126 Avocado Ave Ste 207 · (951) 657-0544 · Call to confirm hours
Pharmacy
Oportun0.3 mi
2560 N Perris Boulevard, Inside Cardenas · (866) 488-6090 · Call to confirm hours
Grocery
Aldi0.3 mi
80 Citrus Ave · (855) 955-2534 · Call to confirm hours
Park
217 Citrus Ave · (951) 943-6100 · 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 4 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 increased11.9%10.2%15.4%better
Long-stay residents who lose too much weight0.3%4.0%5.4%better
Long-stay residents with a catheter left in their bladder2.8%0.8%0.9%worse
Long-stay residents with a urinary tract infection2.2%1.2%2.0%worse
Long-stay residents with depressive symptoms4.0%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 injury1.3%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened7.0%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication28.8%13.7%18.9%worse
Long-stay residents given the seasonal flu vaccine98.2%98.2%95.3%typical
Long-stay residents with pressure ulcers1.2%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control5.4%10.2%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table60.6%12.0%17.1%check this — see note marked dagger below the table
Short-stay residents rehospitalized after admission7.9%23.0%22.6%better
Short-stay residents with an outpatient ER visit11.0%11.2%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.362.251.67worse
Long-stay outpatient ER visits per 1,000 resident days1.071.571.80better

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

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

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

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

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

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

9.0%U.S. median 10.7%
Went back to hospital
84.8%U.S. median 56.6%
Met the expected recovery
0.13U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 84.8% 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 33 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 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.0%CMS range 5.7–13.410.7%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 discharge84.8%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 discharge78.8%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 discharge69.7%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 identified65.9%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 hospitalization5.7%CMS range 3.2–10.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.081.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.46
RN hours/ resident / day
0.86
LPN hours/ resident / day
3.31
Aide hours/ resident / day
4.63
Total nurse hours/ resident / day
0.33
RN hoursweekends
12.5%
Total nursing turnover
18.2%
RN turnover

How full it usually is: this home is certified for 109 beds and averages 100.5 residents a day — about 92% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.31 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.11 hrs/resident/day on weekends vs 4.84 on weekdays — 15% thinner on weekends. RN hours go from 0.52 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 12% 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

1
deficiencies at the latest standard inspection (2024-12-12)
12
at the previous standard inspection (2022-03-18)

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.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · G2022-03-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one out of 95 residents (Resident 75) received the appropriate services needed to maintain acceptable parameters of nutritional status when: 1. Significant severe weight loss of 14 lbs (pounds, a unit of measurement), 6.7 percent (%) from October 14, 2021 to November 11, 2021, 17 lbs, 8% from September 14, 2021 to December 10 2021, 18 lbs, 8.6% from October 14, 2021 to January 18, 2022, 25 lbs, 11.9% from August 23, 2021 to February 8, 2022, and 34 lbs 16.2% from September 14, 2021 to March 2, 2022 were not addressed in the Interdisciplinary Team (IDT) which may include, Physician (MD), Registered Nurse (RN), Dietary Manager/Dietitian (Registered Dietitian, RD), Social Services, Activity Director/Coordinator .weight variance meeting; nor were interventions implemented to prevent further significant severe weight loss, and 2. There was no documented order for a Physician prescribed weight loss regimen. These failures contributed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure:1. 14 of 17 residents reviewed (Resident's 1, 2, 3, 4, 6, 7, 9, 10, 12, 13, 14, 15, 16, and 17) were supervised by the facility staff, as ordered by their physician, during leave of absence passes (LOA); and2. One resident reviewed (Resident 3) did not have sharp objects on the meal trays, as indicated in the residents' care plan.This failure had the potential for:1. Resident's 1, 2, 3, 4, 6, 7, 9, 10, 12,13, 14, 15, 16, and 17 to experience avoidable environment risks, hazards, and accidents; and 2. Placed Resident 3 at risk for self-harm.Findings:On July 30, 2025, an unannounced visit was conducted at the facility to investigate a complaint.1a. On July 30, 2025, Resident 1's medical record was reviewed.Resident 1 was admitted to the facility on [DATE], with diagnoses which included Major depressive disorder (persistent feeling of sadness), paranoid schizophrenia (symptoms of suspicious/mistrust/delusions/hallucination), anxiety…

    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 · E2025-08-04 · tag F0742 — pattern
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 mental health services were provided when:1. The physician or psychiatrist was not notified for one resident (Resident 3) of Resident 3's concern regarding his methadone addiction and possibly experiencing a relapse; and 2. The facility did not arrange psychological evaluations for 12 of 12 residents reviewed (Resident's 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15).This failure had the potential for Resident's 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15 to have a delay in the necessary care and services to address their behavioral health needs. Findings:1.On July 30, 2025, an unannounced visit was conducted at the facility to investigate a complaint.On July 30, 2025, at 12:17 p.m., Resident 3 was interviewed. Resident 3 was alert and oriented. Resident 3 stated he felt the facility was not addressing his problem with methadone (synthetic opioid medication) addiction.On July 30, 2025, Resident 3's medical record was reviewed.The admission…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-09 · 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 observation, interview and record review, the facility failed to ensure an injury of unknown origin was reported immediately, but not later than 2 hours to the State Survey Agency (SSA) and to the Long-Term care (LTC) Ombudsman for one of three sampled residents (Resident 1). The facility was made aware of Resident 1 ' s right arm fracture on May 23, 2025. This failure had the potential for state agencies and the LTC Ombudsman not to be able to advocate for the residents in protecting their rights to be free from abuse and neglect. Findings: On June 9, 2025, at 10:35 a.m., during a concurrent observation and interview, Resident 1 was observed with right arm in a blue sling with right hand contracted. Resident 1 was attempted to be interviewed but only responded with a mumble. A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit and muscle weakness. Further review of the record indicated…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-09 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 investigate what could have caused one of three sampled residents ' (Resident 1) right arm fracture. The facility did not witness the source of the fracture, and the resident could not explain the source of the right arm fracture. This failure had the potential to delay provision of corrective action to ensure Resident 1 is free from potential abuse, neglect, and mistreatment. Findings: On June 9, 2025, at 10:35 a.m., during a concurrent observation and interview, Resident 1 was observed with right arm in a blue sling with right hand contracted. Resident 1 was attempted to be interviewed but only responded with a mumble. A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit and muscle weakness. Further review of the record indicated the resident was transferred to the general acute care hospital (GACH) on May 23, 2025, for 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    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 1 (Resident #24) of 1 sampled resident reviewed for vision/hearing was provided their hearing aid when they were received in the facility. Findings included: An undated facility policy titled, Hearing and Vision Services, indicated, 3. The social worker/social service designee is responsible for assisting residents, and their families, in locating and utilizing any available resources, for the provision of the vision and hearing services the resident needs. An admission Record revealed the facility admitted Resident #24 on 02/21/200605/13/2024. According to the admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease with acute exacerbation. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/02/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. According to the MDS, Resident #24 had minimal…

    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 before2022-03-18 · 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 distribute food in accordance with professional standards for food service safety when: 1. A full sheet deep metal pan of egg salad prepared on March 15, 2022, was found in the reach-in refrigerator without food temperature monitoring for the cool down process; 2. Three various sized cooking pans, readily available for use, had dry and heavy black residue buildup on the cooking surface; 3. Several various sized plastic containers and metal pans were stacked and stored wet; and 4. The kitchen staff did not utilize the correct manufacturer's directions to sanitize the dishes for the manual dishware washing using the 3-compartment sink. These failures had the potential to cause food-borne illness in a medically vulnerable resident population who consumed food from the kitchen. The facility census was 95. Findings: 1. On March 14, 2022, at 3:02 p.m., a full sheet deep metal pan of egg salad prepared on March 14, 2022, was observed in the reach-in refrigerator. Its temperature was taken and 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-03-18 · tag F0908 — failed to keep essential equipment working — widespread
    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 the ice machine in safe operating condition when the ice machine was not cleaned, and the manufacturer's manual was not followed. This failure had potential to cause food-borne illness in a highly susceptible population of 90 out of 95 residents who received food from the kitchen. Findings: A review of facility document titled, Physician Orders List, dated March 14, 2022, indicated 90 residents were on diets and received food from the kitchen. During an observation of the ice machine on March 14, 2022, at 11:25 a.m., there were significant amounts of black and gelatinous residue found behind the bottom of the harvester (a part of ice machine looks like a panel where a sheet of ice cubes slides into the storage bin during the harvest cycle) and could be easily removed with a white paper towel. In addition, there were white deposits found located on the top at the side of the ice storage bin. During an interview on March 14, 2022, at 11:25 a.m. and the follow up interview on March 14, 2022, at 3:41…

    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 before2022-03-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe smoking practices were observed and implemented for three of four residents reviewed for smoking (Residents 24, 3, 18 and 25), when: 1. Resident 24 was observed smoking inside the facility; 2. Resident 3 had his cigarettes and lighter in his possession, offered a cigarette to another resident, and smoked a cigarette himself without staff supervision; 3. Resident 18 stated he usually had his lighter in his possession; and 4. Resident 25 had a cigarette in his possession while inside the facility. These failures had the potential to result in accidents or injuries to the residents. Findings: 1. On March 14, 2022, at 1:20 p.m., Resident 24 was observed in the North hallway, by her room. Resident 24 had, in her possession, a cigarette and a lighter. Resident 24 lit up the cigarette and started smoking inside the facility. Resident 24 continued smoking inside the facility, walked passed several residents' rooms and the nursing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-03-18 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure discontinued and expired medications were not stored in the medication and treatment carts, readily available for use. This failure increased the risk for the licensed nurses to administer discontinued and expired medications to the residents which could result in medication and treatment errors. Findings: 1. On March 16, 2022, at 11:36 a.m., an inspection of the medication cart in the medication room was conducted with RN 2. A medication cart was observed stored inside the medication room. In a concurrent interview, RN 2 stated the medication cart was not used since February 2022. RN 2 stated all medications inside the medication cart were readily available for use. The following medications were stored in the medication cart: -one open bottle of Vitamin C (vitamin/supplement) liquid with an expiration date of November 2021; -one open bottle of ProStat (protein supplement) with an expiration date of June 2021; -one open bottle of Geritussin (cough medicine) with an expiration date of September 2021;…

    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 · E2022-03-18 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    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 one dietary personnel was competent to carry out the functions of the food and nutrition service when one [NAME] (Cook 1) did not monitor and did not know the process for ambient (current air temperature) cool down of Time/Temperature Control for Safety (TCS) foods (cross refer to F812, finding number 1). This failure had the potential to cause food borne illness in a potentially compromised population of 90 out of 95 residents who received food from the kitchen. Findings: During the review of facility document titled, Physician Orders List, dated March 14, 2022, it indicated there were 90 residents who had physician diet orders and received food from the facility kitchen. During the follow-up observation of the reach-in refrigerator in the kitchen on March 14, 2022, at 3:02 p.m., a batch of egg salad in a full sheet and deep metal pan was found with a temperature of 59.9 degrees Fahrenheit (F). During a concurrent interview with [NAME] 1, he stated he prepared it around 2:30 p.m., and stated he did…

    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 16 citations
  • Potential for harm · E2022-03-18 · tag F0803 — failed to meet residents' dietary needs — pattern
    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 menu was followed during the lunch meal on March 15, 2022, when 11 residents with a CCHO (Consistent Carbohydrate to treat medical condition of diabetes) mechanical soft (food was broken down for easy chewing) diet and 21 residents with a CCHO regular (no modification made to food) diet received a whole piece of chocolate cake with whipped topping instead of a half piece. This failure had the potential to result in increased blood sugar levels of 32 residents with a CCHO diet. Findings: On March 15, 2022, at 1:15 p.m., the dietary staff was observed to serve the whole, size of two inches by two inches by half inch (2x 2x 1/2) chocolate cakes to residents receiving regular CCHO and mechanical soft CCHO diets. A concurrent review of the undated departmental menu spreadsheet titled, Spring Cycle menus, week 2 Tuesday 3/15/22 ., indicated residents with a CCHO regular diet and a CCHO mechanical soft diet should have received a half piece of 2x 2x 1/2 chocolate cake with whipped topping. A review of 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 · E2022-03-18 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to develop and implement a policy and procedure for Foods Brought by Family/Visitors, that included provisions on facility providing education and information about safe food handling (such as safe cooling/reheating process, hot/cold holding temperatures, preventing cross contamination, hand hygiene, etc.) practices to residents, family and visitors, and provisions on facility providing training to all facility personnel regarding safe food handling practices who were involved in preparing, handling, serving, or assisting the resident with meals or snacks. This failure had the potential to cause foodborne illnesses in a medically vulnerable population of residents who could consume food and receive food from family or visitors. The facility census was 95. Findings: On March 12, 2022, at 3:35 p.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated family and visitors could bring food for the residents. She stated the food from outside, or leftovers would be kept in the designated resident's refrigerator 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-03-18 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written information on how to formulate an Advance Directive (AD-a written instruction related to the provision of health care when the resident can no longer make decisions), for two of 25 residents reviewed (Resident 54 and 25). This failure had the potential for Residents 54 and 25 to receive unnecessary care/treatment and services. Findings: 1. On March 15, 2022, Resident 54's record was reviewed. Resident 54 was admitted to the facility on [DATE]. The History and Physical dated January 10, 2022, indicated Resident 54 had fluctuating capacity to understand and make decisions. The Physician Orders for Life-Sustaining Treatment (POLST) dated April 21, 2021, indicated Resident 54 was self-responsible and did not have an AD. The facility document titled, ACKNOWLEDGEMENT OF RECEIPT Advance Directive/Medical Treatment Decisions, dated January 10, 2022, indicated Resident 54 was self-responsible. The document did not indicate Resident 54 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-03-18 · 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 for two of three residents reviewed for skin condition (Residents 19 and 5) received the proper care and treatment when: 1a. For Resident 19, the physician's order to give Doxycycline (type of antibiotic medication) for pressure ulcers (PU- an injury caused by prolonged pressure on the skin) was not carried out upon admission to the facility and was not administered to the resident. This failure resulted in Resident 19 not receiving the complete course of antibiotic treatment which may delay the healing process of the multiple infected pressure ulcers; 1b. The facility failed to develop and initiate a baseline care plan to address Resident 19's admitting diagnosis of multiple infected pressure ulcers. This failure had the potential to put Resident 19 at risk for the delay of treatment and intervention to promote the wound healing of the multiple infected PU; and 2. For Resident 5, treatments on the right great toe and right outer…

    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 · D2022-03-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one of two residents reviewed for oxygen administration (Resident 57), when the physician's order for oxygen administration was not followed. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition. Findings: On March 14, 2022, at 9:48 a.m., Resident 57 was observed in bed with oxygen (O2) via nasal cannula (N/C - a tube used to deliver oxygen through the nose). Resident 57's oxygen administration was observed at one liter per minute (LPM). In a concurrent interview, Resident 57 stated she used O2 as needed, when she was short of breath (SOB), and the level should be at three LPM. Resident 57's record was reviewed. Resident 57 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a disease that causes obstructed airflow from the lungs). The physician's order…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-18 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the appropriate food texture for one resident (Resident 76) who was on a NAS (no added salt), CCHO (consistent carbohydrate that treats medical condition of Diabetes Mellitus), mechanical soft texture diet (a diet texture with a soft and chopped or ground texture for one who has difficulty chewing or swallowing) received a whole grilled quesadilla with cubed chicken for an alternate meal at lunch meal on March 15, 2022. This deficient practice had potential for Resident 76 to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway) which could further compromise his medical status. Findings: During lunch meal service observation on March 15, 2022, beginning at 12:09 p.m., Resident 76, with a mechanical soft texture diet order, received a whole grilled quesadilla (brown and crispy tortilla) with cubed chicken as an alternative meal. During a concurrent interview with the Dietary Supervisor (DS), she verified with the cook and stated it was not appropriate.…

    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 before2019-11-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3.On November 5, 2019, at 3:57 p.m., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 1 for Resident 83. CNA 1 stated he just gave Resident 83 a bedbath. Resident 83 was observed with multiple rashes on the right lower extremity (RLE). CNA 1 confirmed Resident 83 had rashes on the RLE. On November 6, 2019, at 1:36 p.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 6. LVN 6 confirmed Resident 83 had multiple rashes on the RLE. LVN 6 stated she was not aware of Resident 83's rashes. On November 6, 2019, Resident 83's record was reviewed. Resident 83 was admitted to the facility on [DATE], with diagnoses including cerebrovascular disease (also called stroke - a condition when blood supply to the brain is stopped either by a blockage or the rupture of a blood vessel). On November 6, 2019, at 3:40 p.m., a concurrent interview and review of CNA's Daily Body Check Report assessment form dated November 5, 2019, p.m.shift and November…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-11-08 · 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 discontinued medications were not stored in the medication cart readily available for use. This failure increases the risk for the licensed nurses to administer discontinued medications to the residents and may result in medication error. Findings: On November 7, 2019, an inspection of the medication cart with an interview and record review was conducted with Licensed Vocational Nurse (LVN) 7. Stored inside the medication cart readily available for use were the following: - One box (25 count of 3 milliliter (ml) solutions) of Albuterol 0.83 % (medication used to treat difficulty of breathing) inhalation solution, labeled as ordered for Resident 22; and - 19 tablets of hydroxyzine HCL (hydrochloride) 25 milligrams (mg), labeled as ordered for Resident 77. In a concurrent interview and record review, LVN 7 stated she did not see in the November 2019 Medication Administration Record, an active physician's order for the Albuterol…

    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 · E2019-11-08 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to implement and observe an infection control and prevention program when multiple residents were not provided withthe appropriate hand hygiene prior to eating lunch. This failure had the potential to result in the transmission of infection to an already vulnerable population of residents in the facility. Findings: On November 5, 2019, at 12:15 p.m., a lunch meal dining observation was conducted in the central dining room with multiple residents. At least 14 residents in the dining room were observed to not receive hand hygiene prior to eating lunch. On November 5, 2019, at 12:55 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated she was assigned to the central dining room to pass trays and to assist residents as needed. CNA 2 stated it was not the policy of the facility to provide hand hygiene to the residents prior to eating their meals in the dining room. CNA 2 further stated all residents should have hand hygiene before eating. On November 5, 2019, at 1 p.m., an interview…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-11-08 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed, for one of seven residents (Resident 40) reviewed, to ensure the resident was afforded the right to receive or refuse medical care and/or treatment. Resident 40, who did not have the capacity to make decisions, sign the acknowledgements for advance directive (AD - written instruction such as living will or durable power of attorney for health care about the provision of care and services the resident preferred when he is no longer able to decide for himself) and Bed Hold Notification. This failure had the potential for the resident to receive unnecessary care/treatment and services. Findings: On November 5, 2019, at 12:02 p.m., an observation was conducted with Resident 40. Resident 40 was observed in bed, agitated, and was swinging his arms and appeared to be talking to himself. Resident 40 was unable to answer questions appropriately when an interview was attempted. On November 6, 2019, Resident 40's record was reviewed. Resident 40 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-08 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on obervation, interview, and record review, the facility failed, for one of 21 residents (Residents 16) reviewed, to ensure the medication hydrocortisone (corticosteroid hormone medication used to treat blood/hormone/immune system disorders, cancer and severe allergies) was given at breakfast, with food or milk, as ordered by physician. This failure had the potential for the resident to experience side effects of the medication if not given as ordered by the physician; and Findings: On November 7, 2019, at 8:51 a.m., a medication pass observation was conducted on Resident 16 with Licensed Vocational Nurse (LVN) 2. LVN 2 prepared Resident 16's medications that included one tablet of hydrocortisone 5 milligrams (mg) that had a label instruction to give one tablet daily at breakfast and to give it with food or milk. On November 7, 2019, at 9 a.m., LVN 2 administered the hydrocortisone tablet to Resident 16 without giving the medication with food or milk. On November 7, 2019, at 9:37 a.m., an interview with a concurrent record review was conducted with LVN 2. LVN 2 verified the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-08 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed, for one of four residents (Resident 23) reviewed for limited Range of Motion (ROM), to ensure the change in the resident's ROM on his right elbow was identified and addressed by the facility. This failure had the potential for the resident to develop further contracture (shortening or hardening of the muscles, tendons, or other tissues, often leading to rigidity and deformity of joints)on his right elbow if left untreated. Findings: On November 5, 2019, at 9:54 a.m., an observation with a concurrent interview was conducted with Resident 23. Resident 23's right arm and hand were observed to be flaccid (limp) and he supported it with his left hand while being interviewed. Resident 23 stated he had weakness on his right arm and hand and he did not do exercises on it. On November 7, 2019, Resident 23's record was reviewed. Resident 23 was re-admitted to the facility on [DATE], with diagnoses that included hemiplegia/hemiparesis (muscle weakness…

    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 · D2019-11-08 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed, for one of 21 residents reviewed for unnecessary medications (Resident 51) to ensure monitoring for adverse consequences (such as signs and symptoms of bleeding and/or bruising) of anticoagulant medication (Apixaban- medications that reduce or prevent blood from clotting), since ordered on September 27, 2019. This failure had the potential for the resident not to be monitored for the adverse effect of Apixaban such as bruising and bleeding. Findings: On November 5, 2019, at 10:28 a.m., an observation was conducted with Resident 51. Resident 51 had multiple bluish skin discolorations on her bilateral forearms. On November 6, 2019, at 3:28 p.m., an observation, interview, record review, was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 confirmed Resident 51 had multiple bluish skin discolorations on her bilateral forearms. Resident 51 was re-admitted to the facility on [DATE], with diagnoses which included anemia (iron deficiency). The…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-08 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed for two of six residents (Residents 55 and 40) reviewed for unnecessary medications to ensure: 1. For Resident 55 the physician failed to document the rationale for the continued use of Ativan, (a medication used to decrease anxiety), as needed (PRN) beyond the 14 days as required; and 2. Resident 40 the physician failed to document the rationale for the continued use of Ativan PRN beyond the 14 days as required. This failure had the potential for Residents 55 and 40 to receive unnecessary medications. Findings: 1.On November 8, 2019, Resident 55's record was reviewed. Resident 55 was admitted on [DATE], with diagnoses which included anxiety. Resident 55's physician order dated January 11, 2019, indicated to give Ativan 1 milligram (MG), as needed (PRN) for anxiety, manifested by (M/B) episodes of restlessness and verbalization of anxiety. The physician's order for PRN Ativan did not have a stop date of 14 days as regulatory requirement. There was no…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-08 · 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, for one of 21 residents (Resident 1), to ensure the medication Emtriva (anti-viral medication used to treat HIV {type of viral infection}) was available and administered to the resident in a timely manner as ordered by the physician. This failure resulted in a significant medication error. Findings: On November 5, 2019, at 10:26 a.m., Resident 1 was observed lying in bed, alert and verbally responsive. Resident 1 stated she did not receive her HIV medication for four days. Resident 1 further stated the Licensed Nurses (LN) told her they will call the pharmacy to order her HIV medication, but until now the LN did not give her medication. On November 5, 2019, at 10:30 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 stated Resident 1's Emtriva 200 mg was not available. LVN 3 confirmed the Emtriva 200 mg was due to be given on November 5, 2019, at 9 a.m. LVN 3 further stated he will call the pharmacy and order the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-11-08 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure safe, sanitary practices for infection prevention for one of 21 residents reviewed (Resident 70) when an undated and unlabeled plastic jar containing brownish liquid and Jalapeno mixture was stored at the resident's bedside. This failure had the potential to result in the development of food-borne illnesses and the growth of microorganism in vulnerable residents. Findings: On November 5, 2019, at 12:13 p.m., an observation and concurrent interview was conducted with Resident 70. Resident 70 was observed lying in bed awake, alert and able to verbalize his needs. A covered plastic container half filled with cut up mix vegetables with Jalapenos and brownish liquid was observed on top of Resident 70's bedside table. The container was undated and unlabeled. In a concurrent interview, Resident 70 stated the container was filled with Jalapeno mix from the can. Resident 70 stated he would request the staff to open the container when he wanted to eat the food item during meals. Resident 70 further stated 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ROLLINS-NELSON HEALTHCARE MANAGEMENT — 8 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 52.4+2.6 vs chain
Health inspection 4 of 52.3+1.7 vs chain
Staffing 4 of 53.0+1.0 vs chain
Quality measures 5 of 54.1+0.9 vs chain
The other 7 homes this chain runs (chain average 2.4★, 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
CENTINELA GRAND, INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 12/11/2009
CENTINELA GRAND PROPERTY, LLCOrganization5% OR GREATER MORTGAGE INTERESTsince 12/01/2009
NELSON, WILLIAMIndividual5% OR GREATER MORTGAGE INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2009
RIZZO, MARICRISIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/07/2025
ROLLINS, VICKIIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 12/01/2009
SIREGAR, GEORGEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/06/2025
MAKANDURA, LAKSHMANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/06/2025

CMS files one row per role, so the 18 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$12.5M
Net patient revenuemost recent cost report
+2.1%
Operating marginrevenue minus expenses
$535K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 20%Medicare 10%Other / private 69%

This home reported $535K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$337per resident / day
operating cost
$10,257per month
≈ monthly operating cost
$345per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 056186. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-12, 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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