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Pleasant Hill Post Acute

1625 Oak Park Boulevard, Pleasant Hill, CA 94523 · For profit - Limited Liability company · 51 certified beds · (925) 935-5222 Medicare & Medicaid certified

Call the home — (925) 935-5222 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 21 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score

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

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3100 Oak Rd Ste 280 · (925) 280-4442 · Call to confirm hours
Pharmacy
Walgreens0.4 mi
2900 N Main St · (925) 933-0307 · Call to confirm hours
Grocery
1512 Sunnyvale Ave · (925) 932-8404 · Call to confirm hours
Park
(888) 327-2757 · 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 fell from 5 to 4 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 rating4★
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 increased0.0%10.2%15.4%check this — see note marked star below the table
Long-stay residents who lose too much weight0.0%4.0%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury6.3%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication20.0%13.7%18.9%typical
Long-stay residents with pressure ulcers0.0%4.3%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control4.8%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 table2.0%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication3.2%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine99.6%93.2%79.4%better
Short-stay residents rehospitalized after admission22.8%23.0%22.6%typical
Short-stay residents with an outpatient ER visit7.4%11.2%12.0%better

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

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

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

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

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

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

63.0% 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 396 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.0%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
69.3%U.S. median 56.6%
Met the expected recovery
0.88U.S. median 0.31
Therapy hours / resident / day
0.47hours / resident / day
Physical therapy
0.34hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 69.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 114 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 0.88 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNF63.0%CMS range 56.9–67.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 7.7–12.710.7%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 discharge69.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge48.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge73.7%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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.5%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 3.6–9.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 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

0.67
RN hours/ resident / day
1.22
LPN hours/ resident / day
2.31
Aide hours/ resident / day
4.20
Total nurse hours/ resident / day
0.49
RN hoursweekends
30.0%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 51 beds and averages 48.7 residents a day — about 95% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 4.20 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.83 hrs/resident/day on weekends vs 4.35 on weekdays — 12% thinner on weekends. RN hours go from 0.74 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 30% 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

12
deficiencies at the latest standard inspection (2025-08-15)
5
at the previous standard inspection (2024-05-16)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · E2025-08-15 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for six of 47 sampled residents (Resident 2, 4, 9, 16, 64, and 68), the facility failed to inform and provide information to the resident and/or resident representatives, the option to formulate an Advance Directive (AD, a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity). This deficient practice had the potential to result in delayed treatment directions to healthcare providers regarding residents' medical care. 1. A review of Resident 2's admission Record, printed on 8/14/25, indicated resident was admitted to the facility on [DATE], with diagnoses that included hemiplegia (muscle weakness on one side of the body, complete paralysis) and hemiparesis (partial weakness), atrial fibrillation, (an irregular, often rapid heart rate that causes poor blood flow), and diabetes mellitus (high blood sugar). 2. A review of Resident 4's admission 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-15 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services to meet professional standards of quality for three of three sampled residents (Residents 64, 34, and 67) when the following were observed:1. Resident 64's Fiber source enteral feeding bag (food given through a feeding tube) and tubing were not labeled.2. Resident 34's Intravenous (IV - small flexible tube used to deliver medicine/fluids into a person's vein) secured by tegaderm (clear, waterproof medical device to secure IV line to a person's skin) was not labeled.3. Resident 67's IV line and tubing was not labeled.This failure had the potential to negatively impact the delivery of care services provided to Residents 64, 34 and 67.1. During a review of Resident 64's admission Record, printed on 8/15/25, indicated Resident 64 originally admitted to the facility on [DATE] and was re-admitted on [DATE] with multiple diagnoses which included malnutrition and dysphagia (difficulty swallowing).During a review of Resident 64's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-15 · 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 failed to ensure medication error rate was below five percent (%) when:1. Licensed Vocational Nurse (LVN) 2 administered three antihypertensive (medication to treat high blood pressure) medications to Resident 72 without checking vital signs prior to administering the medications.2. LVN 1 administered topical medication to Resident 45 without doctor's order.These deficient practices placed Residents 72 and 45 at risk of developing complications and adverse reaction related to error in medication administration. 1. During concurrent medication administration observation and interview on 8/14/25, at 9:18 a.m. with LVN 2, LVN 2 was doing morning medication pass. LVN 2 administered Bumetanide 2mg 1 tablet, Carvedilol 6.25mg 1 tablet, and Losartan 100mg 1 tablet by mouth to Resident 72 without checking vital signs.LVN 2 stated she did not check Resident 72's vital signs because she relied on Certified Nursing Assistants (CNA - unlicensed direct care…

    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 · E2025-08-15 · tag F0760 — failed to prevent significant medication errors — pattern
    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 resident of 27 (Resident 72) sampled residents observed during medication administration pass was free from significant medication error when Licensed Vocational Nurse (LVN) 2 administered the following medications without checking Resident 72's vital signs (clinical measurements that tells the state of essential body functions).1. Bumetanide (a powerful water-pill that can lower blood pressure) 2 milligrams (mg - unit of measurement)2. Carvedilol (antihypertensive - medication to treat high blood pressure)3. Losartan (antihypertensive- to treat high blood pressure)This deficient practice had the potential for dangerous drop in blood pressure, possible for stroke and increased risk of death.During a review of Resident 72's admission record printed on 8/14/25, indicated Resident 72 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with multiple diagnoses that included essential primary hypertension…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner when:1. Two dietary staff members did not have their hair fully covered with a hairnet. 2. Plate covers and plate bases used were worn out and damaged. 3. A ladle spoon was found stored dirty and in poor condition. 4. Kitchen storage cabinet doors for storing food and cooking equipment were either missing or in poor condition. These failures had the potential to result in contamination of food and foodborne illness for 46 residents who received food from the kitchen out of a facility census of 47. 1. During a concurrent observation and interview on 8/13/25, at 12:40 p.m., with [NAME] 1 and Dietary Aide 1, both dietary staff members did not have their hair fully secured with a hairnet. [NAME] 1's hair to the back of her neck was not fully covered with the hairnet. Dietary Aide 1 was also noted with some hair to both sides of her neck that were not fully secured 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident's food items brought from outside and stored in the residents' refrigerator located in the Conference Room, were labeled and stored appropriately for one of 47 sampled residents (Resident 19).These failures had the potential to cause food contamination and foodborne illnesses.A review of Resident 19's admission Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 6/13/25, indicated resident was admitted to the facility on [DATE], with a therapeutic diet (a meal plan) order.During a concurrent observation, interview, and record review, on 8/13/25, at 3:15 p.m., with the Infection Preventionist (IP) and Dietary manager (DM), in the conference room, contents of the facility's refrigerator and freezer designated for residents' food brought from outside were checked. Items found were Resident 19's liquid food Items that were stored in the refrigerator, with no received date, open date, use-by date, or…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-15 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow infection control practices when following were noted:1. Doors of four out of five sampled rooms designated for COVID-19 (a disease caused by coronavirus that spreads through the air when an infected person coughs, sneezes, or talks. It can cause fever, cough, tiredness, and trouble breathing, and can be more serious in older adults or people with health problems) residents were left open.2. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene after touching resident care areas and prior to serving food to Resident 51.3. Resident 57 did not have hand hygiene supplies readily available and within easy reach, to clean his hands after coughing up phlegm (yellow thick mucus).4. Oxygen tubing (a clear flexible hose that delivers oxygen from tank) for one of two sampled residents (Resident 16) was not labeled and was kept off the floor. 1. During a concurrent interview and record review on 8/12/25, at 11:50 a.m., with…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-15 · tag F0573 — isolated
    Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
    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, for one of one sampled resident (Resident 63), the facility failed to ensure Resident 63 was allowed to obtain a copy of his requested medical records within the required time frame.This failure resulted in Resident 63's undue concern and anxiety pertaining to obtaining the requested medical records and contact number of his former physician.A review of Resident 63's admission Record, printed on 8/14/24, indicated that resident was admitted to the facility on [DATE] and discharged to home upon completion of care on 4/16/23. A review of Resident 63's admission Minimum Data Set (MDS, a resident assessment tool used to provide care) dated 3/15/23, indicated resident was understood, able to understand others, and had a Brief Interview of Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS score ranges from 0-15, with 15 as an indication of intact skills) score of 15. A review of Resident 63's letter of request for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-15 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 complete the tracking entry Minimum Data Set (MDS - a federally mandated assessment tool) within seven calendar days after re-entry for one of 47 sampled residents (Resident 64). This failure had the potential to delay care planning and delivery for Resident 64's care areas that would have been identified in the re-entry MDS.During a review of Resident 64's admission Record, printed on 8/15/25, indicated Resident 64 originally admitted to the facility on [DATE] and was re-admitted on [DATE] with multiple diagnoses that included anoxic brain damage (caused by complete lack of oxygen to the brain), acute respiratory failure with hypoxia (lung condition where lungs cannot provide enough oxygen to the body), malnutrition, contracture (stiff joint/body part and unable to move normally) of left and right knee, and personal history of malignant neoplasm of breast (breast cancer).During a review of Resident 64's Nursing Home and Swing Bed Tracking (NT/ST) MDS…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-15 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    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, for one of 47 sampled residents (Resident 64), the facility failed to complete the quarterly Minimum Data Set (MDS - a federally mandated assessment tool) assessments. This failure had the potential to result in the delayed assessment of resident needs, goals of care and inability to monitor each resident's progress over time.During a review of Resident 64's admission Record, printed on 8/15/25, indicated Resident 64 originally admitted to the facility on [DATE] and was re-admitted on [DATE] with multiple diagnoses that included anoxic brain damage (caused by complete lack of oxygen to the brain), acute respiratory failure with hypoxia (lung condition where lungs cannot provide enough oxygen to the body), malnutrition, contracture (stiff joint/body part and unable to move normally) of left and right knee, and personal history of malignant neoplasm of breast (breast cancer).During a concurrent interview and record review on 8/15/25 at 12:11 p.m. with Minimum Data Set…

    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
Show the remaining 11 citations
  • Potential for harm · D2025-08-15 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 that one of three residents (Resident 57) received a thorough assessment and individualized activities program designed to meet his interests for almost two weeks.This failure resulted in Resident 57 feeling frustrated and placed him at risk for isolation.During a review of Resident 57's admission Record printed on 8/14/25, the record indicates Resident 57 was admitted to the facility on [DATE].During a review of Resident 57's Minimum Data Set (MDS-federally mandated resident assessment tool) assessment dated [DATE], the assessment indicated Resident 57 was able to understand others and was able to make himself understood. The assessment indicated it was very important for Resident 57 to listen to music he liked, to be around animals such as pets, to keep up with the news, and to do his favorite activities.During a concurrent observation and interview with Resident 57 on 8/12/25 at 10:12 a.m. in his room, Resident 57 was sitting up…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-15 · 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 to ensure that one of five sampled residents (Resident 68) was not given unnecessary anticoagulant (a prescription medication and powerful blood thinner) medication without a doctor's order. This failure resulted in Resident 68 to receive anticoagulant medication unnecessarily and posed a significant health risk, potentially leading to serious and life-threatening outcome.During a review of Resident 68's admission record, printed on 8/15/25, indicated Resident 68 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. During a review of Resident 68's Minimum Data Set (a federally mandated assessment tool) dated 5/11/25, indicated Resident 68 had multiple diagnoses that included Cerebrovascular Accident (CVA or stroke, where blood vessels in the brain suddenly ruptures and bleeds into the brain).The MDS revealed Resident 68 was taking anticoagulant.During a concurrent interview and record review on 8/15/25 at 1:30 p.m. with the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-15 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 that Resident 57's call bell was answered in a timely manner. Resident 57's call system consisted of a standalone call bell, not connected to the call light monitoring panel situated at the nursing station. The call bell did not activate a visual signal outside the room and did not allow tracking of response times. Staff did not respond to Resident 57's call promptly on multiple occasions.This failure resulted in Resident 57 feeling frustrated and placed him at risk for unmet care needs while he was already quarantined for COVID-19 infection. During a review of Resident 57's admission Record printed on 8/14/25, the record indicated Resident 57 was admitted to the facility on [DATE].During a review of Resident 57's Minimum Data Set (MDS-an assessment tool used to direct resident care) assessment dated [DATE], the assessment indicated Resident 57 was able to understand others and was able to make himself understood. During 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-16 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a comprehensive admission Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) assessment was completed within 14 calendar days of admission date for three of three sampled residents (Resident 45, Resident 313, Resident 317). This deficient practice resulted in delayed completion of admission assessment and had the potential to result in Resident 45, 313, and 317 not receiving the appropriate care and services needed based on their health status. Findings: During a review of Resident 45's admission Record (a document used to communicate basic information about a resident), dated 5/14/24, the admission Record indicated Resident 45 was admitted to the facility on [DATE]. During a review of Resident 313s admission Record, dated 5/16/24, the admission Record indicated Resident 313 was admitted to the facility 12/8/23. During a review of Resident 317's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-16 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    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 three of three sampled residents' (Resident 45, 315 and 316)'s Minimum Data Set (MDS, an assessment tool used to guide resident care) discharge assessments were completed within 14 days from their discharge date from the facility. This deficient practice has the potential to result in inaccurate census of the facility that may interfere with accurate planning for safe staffing. Findings: During an interview on 5/16/24 at 10:04 a.m. with Minimum Data Set Coordinator 1 (MDSC 1), MDSC 1 stated she was aware of the late MDS discharge entries. MDSC 1 stated there was no facility protocol on MDSC policies. During a concurrent interview and record review on 5/14/24, at 10:54 a.m., with MDSC 1, Resident 45's discharge MDS assessment was reviewed. MDSC 1 stated Resident 45 was discharged from facility on 1/9/24 and his MDS discharge was not completed until 2/14/24. MDSC 1 stated late completion of discharge MDS assessments resulted in an inaccurate reflection of resident census at the facility which could potentially…

    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 · Ecited before2024-05-16 · 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 prepare and serve food under safe and sanitary conditions when: - moldy and unusable foods were not discarded. - dented can was stored. - food items in dry storage room were not sealed. These failures placed the facility's 45 residents who received food from the kitchen at risk of foodborne illness. During initial observation of the kitchen on 5/13/24 at 9:43 a.m. accompanied by Registered Dietician (RD), showed the following: (a) opened bag with 16 moldy and unusable French bread were stored in the dry storage room labeled with received by 5/8/24 and used by 5/10/24 (b) dented can of six ounce of unsweetened applesauce was stored with remaining stock in dry storage room (c) opened box of hashbrown was not sealed (d) opened box of brown rice was not sealed. During a concurrent interview and observation on 5/13/24 at 9:53 a.m. with RD, RD acknowledged there were moldy French bread rolls stored that should have been discarded. RD stated the person who received supplies should have separated dented can from 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 · Dcited before2024-05-16 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility had a 13.79% medication error rate when four medication errors out of 29 opportunities were observed during medication administration for two of four sampled residents (Resident 165 and 264). Resident 165 did not receive an eye drop and an oral medication according to the physician's order. Resident 264's medication did not have a prescribed dosage for cholecalciferol (used to treat or prevent vitamin D deficiency). These failures resulted in medication not given in accordance with the prescriber's orders, which may negatively affect the resident's health. Findings: 1. During medication administration observation on 5/14/24 at 9:05 a.m., Licensed Vocational Nurse (LVN) 1 was observed preparing and administering six medications to Resident 264. These medications included one tablet of Vitamin D3 (cholecalciferol) 10 micrograms (mcg), two tablets of stool softener 100 milligrams (mg), Fluticasone (medication that treats allergy symptoms like sneezing, itching and a runny or stuffy nose) 50 mcg nasal spray, one tablet of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-16 · 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 that food was stored under sanitary conditions when multiple undated food items were stored in the freezer, refrigerator and the dry storage room. This deficient practice had the potential of putting residents at risk for food-borne illness. Findings: During the initial kitchen tour with the Dietary Manager (DM) on 6/13/22 at 9:47 a.m., the following was observed in freezer #1: two bags of chicken breasts, one bag of veggie burgers, one roll of ground turkey, and two peach pies with no received dates or use by dates. During an interview with DM on 6/13/22 at 9:58 a.m., DM stated all food items needed to be labeled with receive dates and use by dates so the dietary staff can know when the food came in and when it needed to be discarded. DM stated labeling food items let the staff know if the food was still good. During the initial kitchen tour on 6/13/22 at 10:19 a.m., the following was observed in freezer #2: one angel food cake and one bag of snap peas with no received dates or use by dates. 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 · D2022-06-16 · tag F0730 — isolated
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to perform Annual Performance Evaluations for two of two Certified Nursing Assistants (CNAs), CNA 1 and CNA 2. This failure had the potential for the facility to employ problematic staff. Findings: During a concurrent interview and record review on 6/15/22 at 12:05 p.m., with the Director of Staff Development (DSD), CNA 1's personnel file was reviewed. CNA 1's Notice to Employee document, dated 8/16/18 indicated CNA 1 was hired on 8/16/18. DSD stated CNA 1 did not have an Annual Performance Evaluation since CNA 1's date of hire. During a concurrent interview and record review on 6/15/22 at 12:09 p.m., with (DSD), CNA 2's personnel file was reviewed. DSD stated CNA 2 did not have an Annual Performance Evaluation since 11/1/2017. During an interview on 06/15/22 at 12:17 p.m., with DSD, DSD stated she was hired on 6/1/21 and she did not perform any Annual Performance Evaluations for any CNAs since she was hired. DSD stated Annual Performance Evaluations could find problematic staff, which was important because not all residents…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-08-15 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 and interview, the facility failed to provide at least 80 square feet for each resident in multiple resident bedrooms: Rooms 14, 15, 12, 16, 17, 18, 19, 20, 21, and 22.This failure had the potential to result in a lack of sufficient space for facility staff to provide proper care and increased the risk of not having enough room to store resident belongings at their bedside.During random interviews and observations of care and services from 8/12/25 to 8/15/25, there were adequate space for residents' belongings and for caregivers to provide care in all of the rooms listed. There were no complaints from residents or staff regarding the room space.During a record review of the Client Accommodations Analysis, dated 8/12/25, the following multiple resident rooms were identified having below the required 80 square feet requirement per resident:room [ROOM NUMBER] had 4 beds and 68.5 sq.ft./bedroom [ROOM NUMBER] had 4 beds and 68.5 sq.ft./bedroom [ROOM NUMBER] had 2 beds and 49.5 sq.ft./bedroom…

    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
  • No harm found · Bcited before2024-05-16 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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, interviews and record review, the facility failed to provide at least 80 square (sq) feet (ft) of living space per resident for 24 residents who occupied the following multiple resident bedrooms: Rooms 12, 14, 15, 16, 17, 18, 19, 20, 21, and 22. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and a lack of sufficient space for residents to have personal belongings at the bedside. Findings: During random interviews and observations of care and services from 5/13/24 to 5/16/24, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents' care, and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the identified rooms. During 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.

    Environmental 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 PACS GROUP — 274 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 3 of 52.5+0.5 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 273 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Anchor Post AcuteAiken, SC 1 of 5Arbor Post AcuteChico, CA 1 of 5Artesia Palms Care CenterArtesia, CA 1 of 5Arvin Post AcuteArvin, CA 1 of 5Ashland Post AcuteAshland, OR 1 of 5Bakersfield Post AcuteBakersfield, CA 1 of 5Beachwood Post-Acute & RehabSanta Monica, CA 1 of 5Brookshire Post AcuteDenver, CO 1 of 5Brushy Creek Post AcuteGreer, SC 1 of 5Buckeye Care And RehabilitationLancaster, OH 1 of 5Carnegie Park Post AcutePittsburgh, PA 1 of 5Cascade Terrace Post AcutePortland, OR 1 of 5Centennial Post AcuteAnchorage, AK 1 of 5Chandler Creek Post AcuteGreer, SC 1 of 5Chehalem Post AcuteNewberg, OR 1 of 5Country Hills Post AcuteEl Cajon, CA 1 of 5Delhi Post-AcuteCincinnati, OH 1 of 5Dublin Post AcuteDublin, OH 1 of 5Edisto Post AcuteOrangeburg, SC 1 of 5Evan Terrace Post AcuteMcMinnville, OR 1 of 5Forest Acres Post AcuteColumbia, SC 1 of 5Grandview Post AcuteCookeville, TN 1 of 5Great Plains Post AcuteWichita, KS 1 of 5Hemet Hills Post AcuteHemet, CA 1 of 5Highland Hills Post AcutePittsburgh, PA 1 of 5Highline Post AcuteDenver, CO 1 of 5Johns Island Post AcuteJohns Island, SC 1 of 5Karcher Post AcuteNampa, ID 1 of 5Kennedy Care CenterLos Angeles, CA 1 of 5Kern River Transitional CareBakersfield, CA 1 of 5Lakeview Post AcuteFlorissant, MO 1 of 5Marion Valley Post AcuteMarion, OH 1 of 5Mirage Post AcuteLancaster, CA 1 of 5Monroeville Post AcuteMonroeville, PA 1 of 5Napa Post AcuteNapa, CA 1 of 5North Royalton Post AcuteParma, OH 1 of 5Northstar Post AcuteCarson City, NV 1 of 5Overland Park Post AcuteOverland Park, KS 1 of 5Pikes Peak Post AcuteColorado Springs, CO 1 of 5Ridgeway Post AcutePetaluma, CA

Showing 40 of 273; lowest-rated first.

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
PROVIDENCE GROUP NORTH LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 06/01/2016
BILLS, CRAIGIndividualW-2 MANAGING EMPLOYEEsince 08/01/2017
APT, FREDERICKIndividualCORPORATE OFFICERsince 01/01/2024
JERGENSEN, JOSHUAIndividualCORPORATE OFFICERsince 01/01/2024
MITCHELL, JOHNIndividualCORPORATE OFFICERsince 01/01/2024

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.

$16.0M
Net patient revenuemost recent cost report
+28.5%
Operating marginrevenue minus expenses
$843K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 4%Medicare 53%Other / private 43%

This home reported $843K 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

$671per resident / day
operating cost
$20,411per month
≈ monthly operating cost
$939per 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 055049. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-15, 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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