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Red Bluff Health Care Center

555 Luther Road, Red Bluff, CA 96080 · For profit - Corporation · 58 certified beds · (530) 527-6232 Medicare & Medicaid certified

Call the home — (530) 527-6232 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jan 2026Behavioral-health or dementia-care citations — no harm found (F0740, F0758)$31,757 in federal fines
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)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $31,757 in federal fines (most recent 2023-10-02)
  • 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) 4 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
★★★★ 4/5 CMS
Urgent care / clinic
1425 Montgomery Rd · (530) 528-8600 · Call to confirm hours
Pharmacy
Walgreens0.1 mi
1145 S Main St · (530) 528-0478 · Call to confirm hours
Grocery
Raley's0.2 mi
725 S. Main St.
Park
1500 S Jackson St · (530) 527-8177 · Typically dawn to dusk
Place of worship
625 Luther Rd · (530) 527-0445

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 increased14.1%10.2%15.4%typical
Long-stay residents who lose too much weight3.8%4.0%5.4%better
Long-stay residents with a catheter left in their bladder1.5%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened11.2%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.6%13.7%18.9%typical
Long-stay residents given the seasonal flu vaccine92.3%98.2%95.3%typical
Long-stay residents with pressure ulcers4.3%4.3%4.7%typical
Long-stay residents with worsening bladder/bowel control18.6%10.2%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table6.4%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine95.9%93.2%79.4%better
Short-stay residents rehospitalized after admission18.0%23.0%22.6%better
Short-stay residents with an outpatient ER visit19.1%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.072.251.67better
Long-stay outpatient ER visits per 1,000 resident days1.211.571.80better

* 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.

57.6% 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 233 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.6%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
54.4%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 54.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 92 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 83% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.6%CMS range 51.3–64.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 7.2–13.710.7%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 discharge54.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge60.9%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 discharge63.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 discharge94.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.6%CMS range 3.4–8.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.951.02Oct 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

0.33
RN hours/ resident / day
1.01
LPN hours/ resident / day
2.41
Aide hours/ resident / day
3.75
Total nurse hours/ resident / day
0.30
RN hoursweekends
32.1%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 58 beds and averages 54.3 residents a day — about 94% occupied, or roughly 4 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 3.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.41 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 3.70 hrs/resident/day on weekends vs 3.78 on weekdays — 2% thinner on weekends. RN hours go from 0.35 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below the national median of 45%.

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

Inspection trend

11
deficiencies at the latest standard inspection (2026-01-23)
4
at the previous standard inspection (2025-01-10)

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.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · D2026-06-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 residents who were incontinent (involuntary loss of control) of bladder were assessed and provided appropriate treatment and services to maintain or improve continence to the extent possible for one of five sampled residents (Residents 1) when:1. Resident 1 did not receive a bowel and bladder assessment as needed (PRN).2. The Interdisciplinary Team (IDT, a group of healthcare disciplines that develop plans of care) did not re-evaluate Resident 1's incontinent status after changes in urinary status and update care plan as indicated.These failures had the potential to contribute to residents' decline or lack of improvement in urinary continence and or loss of bladder control and function.Findings:1. A review of the facility's policy titled, Bowel and Bladder Management Program, dated 10/21/2010, indicated Purpose to ensure that a resident who is incontinent of bowel and bladder receives the necessary care and treatment. 2. A bowel and bladder…

    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 · D2026-06-09 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    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 one of five sampled residents (Resident 1), had a behavioral health evaluation and services to meet psychiatric behavioral needs.This had the potential for Resident 1 to be at risk for worsening psychiatric symptoms, decline in their physical, emotional, and psychosocial well-being and unmet mental health needs.Findings:A review of a facility policy titled Behavior Management and Documentation of Behaviors: dated 9/1/2008, indicated B. Implement Interventions to Alleviate Possible Causal Factors. 7. Identify the additional resources if residents do not respond to usual interventions and forward slash or medications through the interdisciplinary team process comma case managers etc. C. Evaluate Outcome of Non-Drug Interventions 8. Review residence behavior symptoms and response to medication during the IDT and more often if indicated. Document all assessments, interventions and outcomes in the medical record.A review of Resident 1's clinical…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-04-21 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility's Administrator (ADMIN) failed to ensure resident rights were honored during care when:1. Four out of seven residents reported that Certified Nursing Assistant (CNA A) did not treat them with respect, did not consider their self-determination, and individuality when she provided care. 2. Nursing administrative staff did not provide oversight and provide education/feedback to CNA A after multiple resident complaints. Refer to F550.This resulted in a violation of four residents' rights to receive individualized respectful care and put all residents at risk for not receiving dignified care. Refer to F550.Findings:During a review of the facility Position Description for Administrator dated October 2003, indicated Position Summary The administrator is responsible for the day-to-day operations of the facility in accordance with the applicable policies and procedures, Corporate Integrity Agreement, current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. The administrator is…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-21 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 Certified Nursing Assistant (CNA A) provided residents with dignity and respect during direct resident care for four of seven sampled residents (Resident 1, 2, 3 and 4) when:1. CNA A was rough when providing care to Resident 1.2. CNA A ignored Resident 2's verbal request to be careful with her shoulder during care.3. CNA A did not listen to or provide individualized care to Resident 3.4. CNA A's behavior during care was not respectful toward Resident 4.This failure resulted in a violation of four residents' rights to receive individualized respectful and dignified care.Findings:During a review of the facility position description for Nursing Assistant State Certified/Licensed (CNA), dated October 2003, the Position Summary indicated that the CNA is Responsible for providing residents with routine daily and restorative nursing care and services in accordance with the resident's assessment, care plan and as directed by supervisors. Ensures…

    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 · Ecited before2026-01-23 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 policy review, the facility failed to maintain the facility in a clean, safe and comfortable home-like environment when:1. The sliding glass door in room [ROOM NUMBER] did not lock properly.2. room [ROOM NUMBER] had buckled, worn brown flooring that was on the right side of the sliding glass door, which made this door hard to slide.3. There was a hole in the bathroom door in room [ROOM NUMBER].4. The bathrooms on the south hall, rooms 14 through 25 needed repair and paint.5. The sliding glass doors were hard to open and slide and unclean in 10 resident rooms on the south hall.6. The nurses' station had chipped and worn areas around the sink and the molding and flooring.7. The Brio water fountain in the front lobby had a stained, unclean drain for the resident and community use. This failure had the potential to negatively affect client's health, safety, and comfort and the potential to spread other bacteria in the facility to other residents, staff, visitors, and 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-23 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 seven of eight sampled residents knew the correct procedure to file a grievance with the facility (Resident 1, Resident 19, Resident 22, Resident 23, Resident 25, Resident 39, Resident 45), three of the eight sampled residents were not informed of the findings of the investigations or any corrective actions that were taken for their grievances, (Resident 1, Resident 19, Resident 22), and three of the eight sampled residents stated that they were fearful of retaliation if they filed a grievance (Resident 22, Resident 39, and resident 45).This deficient practice had the potential for residents to be unaware or confused about the process for filing grievances, for grievances to be left uninvestigated or corrected, or residents not being informed of the actions taken for their grievances and for residents to have a concern of retaliation if they filed a grievance or complaint. During a record review of facility policy titled Investigating…

    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 · E2026-01-23 · tag F0609 — failed to report abuse allegations — pattern
    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 interviews, and record reviews, the facility failed to report allegations of mistreatment, made by five of eight sampled residents (Resident 1, Resident 19, Resident 22, Resident 25, and Resident 39) to the appropriate local, state, and federal agencies nor were the residents informed of the progress of an investigation.This failure caused resident complaints/concerns of mistreatment by staff to go unreported with the potential of continued mistreatment, physical and/or psychosocial harm to residents. During a record review of facility policy titled Abuse Investigation and Reporting revision date 07/2017 indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Facility policy also indicated, The Administrator…

    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 · Ecited before2026-01-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    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 ensure oxygen equipment was stored and dated per policy for two out of three sampled residents (Resident 1 and Resident 31) when the oxygen tubing for Resident 1 and Resident 31 was lying on their wheelchairs, uncovered and not dated.This failure had the potential to contaminate the oxygen tubing and cause an infection to the residents which could spread to other residents, staff, and visitors. Findings:During a review of the facility's policy and procedure (P&P) titled, Oxygen Storage and Use, dated 10/22/2010, the P&P indicated, to provide safe storage and use of oxygen. The oxygen cannula, mask etc. shall be changed when soiled. The cannula, mask, etc. shall be stored in a plastic bag when not in use. Logging and changing of oxygen shall be completed per facility policy.During a review of Resident 1's admission Record, dated 11/3/25, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included acute and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-23 · tag F0730 — pattern
    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 complete annual performance evaluations for four of five sampled Certified Nursing Assistants (CNAs - CNA C, F, G and H).This failure had the potential for direct care staff not to provide quality of care and meet the needs of the residents.During a record review of facility policy titled Performance Evaluations dated 2001 MED-PASS indicated, A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually, thereafter. The performance evaluation meeting will occur at the same time as the employee's compensation review. Facility policy further indicated Performance evaluations may be used in determining employee promotions, shift/position transfers, demotions, terminations, wage increased, etc., and to improve the quality of the employee's work performance.During a record review of CNA C's employment file, CNA C was hired on 9/14/22. CNA C did not have performance evaluations completed for 2024.During a record review of CNA F's employment file, CNA F…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-23 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to maintain the food preparation and service areas in a clean and sanitary condition, when the following was identified:A visibly dirty dishwasher.Visibly soiled fans, including an air-conditioning fan located in the pantry.Dirty hanging light fixtures with visible debris.Visibly soiled ceiling above cooking area.An open container of cheese without proper covering.Resident Refrigerator visibly soiled and holding expired items.This had the potential to contaminate food and place residents at risk for foodborne illness. 1.During a concurrent interview and record review on 1/23/26 at 10:20 a.m. with the Nutritional Services Director (NSD), the facility's policy and procedure titled Dishwashing Machine Operation, dated 2020, was reviewed. The NSD confirmed that the policy indicated the dishwashing machine was to be checked for cleanliness prior to the start of each meal service, wiped down per equipment cleaning procedures, and maintained free of built-up debris and lime scale as necessary. During a concurrent…

    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 18 citations
  • Potential for harm · Dcited before2026-01-23 · 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 interview and record review, the facility failed to ensure accurate documentation of psychiatric (mental health) diagnosis in the medical records for one out of 30 sampled residents (Resident 6) based on standards of practice. This failure could lead to inaccurate treatment and monitoring of Resident 6's psychotropic (medications that affect mood or behavior) medication use.Review of Resident 6's medical record, titled Order Summary Report (a list of all doctor orders and medical conditions), dated 1/2026, the record indicated Resident 6 was on a medication called Seroquel (or quetiapine, a medication used to treat the mood and mental health issues) for bipolar disorder (a chronic mental illness that fluctuated between depression and anxiety) as follow: SEROquel Tablet 25 MG (quetiapine; MG means milligram, a unit of measure); Give 2 tablets by mouth at bedtime for Bipolar m/b (manifested by) manic episodes (mania means abnormally elevated, euphoric, or irritable mood, accompanied by intensely high energy and activity levels) . start date : 2/13/2025. Further 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-23 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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 accurate documentation and ongoing pain assessment for one of five residents reviewed for unnecessary medication use (Resident 31).This failure had the potential for unsafe mediation use and risk of adverse effects from opioid use including difficulty breathing and mental confusion. Findings: During a review of Resident 31's medical record indicated that Resident 31 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a serious condition where the lungs can't pump enough oxygen into the blood), chronic obstructive pulmonary disease (COPD - a progressive lung disease that restricts airflow, making it difficult to breath), diabetes (blood sugar disease), in addition to chronic pain. During a record review of the Resident 31's Order Summary Report, dated 1/2026, the record indicated the following pain medication orders: Morphine Sulfate . Oral Solution 20 MG/ML (opioid pain medication; MG/ML is milligram per…

    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 · D2026-01-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure safe use and accountability of narcotic controlled medication (opioid drugs of abuse) use when: Resident 46's Norco (a combination opioid pain medication) was removed from the Controlled Drug Record (CDR - an accountability sheet that tracked narcotic removal with nurse initial, date, and time) without the corresponding documentation in the Medication Administration Record (MAR - a legal document where nursing staff documented medications given to residents). This failure had the potential to contribute to unsafe drug handling, poor pain control, and risk of drug diversion (drug loss). Findings:During a review of Resident 46's medical record indicated that Resident 46 was admitted to the facility on [DATE] with diagnoses that included arthritis, chronic pain, and diabetes (blood sugar disease). A review of Resident 46's MAR, dated 1/2026, indicated the following order for pain management: Norco. take one tablet by mouth every four hours as…

    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 · D2026-01-23 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure safe storage of medication and supplies with a census of 52 residents when:Medication room refrigerator stored expired and discontinued medications, and the refrigerator temperature was not monitored twice daily for vaccine storage.Medication cart stored undated and expired medications. These failures had the potential to contribute to unsafe medication use and risk of ineffective medications reaching vulnerable residents in the facility. Findings: 1a. During a concurrent inspection of facility main medication room accompanied by the Assistant Director of Nursing (ADON), on 1/20/26 at 9:23am, the following issues were noted: a. a bag of Vancomycin (antibiotic in injection form) had expired on 1/1/26. b. an open vial of Tuberculin Purified Protein Derivative Solution (PPD - testing agent for tuberculosis a dangerous lung disease) dated 9/11/25. The manufacturer label on the vial indicated that the vial should be discarded 30 days after being opened. The ADON acknowledged the findings and stated that…

    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 before2026-01-23 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure compliance with infection prevention practices with census of 52 residents when:1. Blood Pressure (or BP, the force of blood pushing against the walls of arteries as the heart pumps it around the body) device cuff was not cleaned after Resident 46 use.2. The pill cutter stored in the medication cart had white powder like residues inside the device.These failed practices could contribute to unsafe care and spread of infection in the facility.Findings:1. During a medication administration observation, in South hall, accompanied by Licensed Nurse J (LN J), on 1/20/26, at 8:33 AM, LN J took up a blood pressure device into the Resident 46 room. LN J wrapped the BP cuff around Resident 46's arm and measured the blood pressure. LN J upon exit from the room, placed the BP device/cuff on where two other BP cuffs hanging on the side of the mobile medication cart. LN J did not clean the BP cuff and continued with medication administration.In an interview with LN J, in the South hall, on 1/20/26, at 8:55 AM, LN J…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-10 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 a clean, safe, comfortable, and homelike environment for seven of 18 sampled residents (Residents 12, 18, 19, 31, 34, 42, and Resident 153) when: 1. Four of Four stand up mechanical lifts were unclean. 2. Patio doors to multiple resident rooms were unkept and unclean with cumulative dust and dark and brown debris. 3. Cumulative food and debris was on the floor and under the wooden side table in room [ROOM NUMBER] A. 4. A side table was unkept, faded, with visible chips in the wood in room [ROOM NUMBER] A. 5. Tile was missing on the floor in room [ROOM NUMBER] A. 6. A foot board was unkept, damaged, and had visible chips in the wood in room [ROOM NUMBER] A. 7. Resident privacy curtains had visible red and brown colored stains. 8. The curtains and tracks of the sliding glass doors in the resident rooms were unclean. This failure had the potential to negatively affect client's health, safety, and comfort and the potential to spread other bacteria in…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-10 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that Resident 19 was administered an inhaler without following manufacturer's instructions to meet Professional Standards of Care. This failure resulted in and had the potential for the medication to be ineffective for all residents that were ordered an inhaler routinely or as needed (prn). Findings: During a review of a policy revised 10/2021, titled, Administering Medications through a Metered Dose Inhaler, indicated the purpose of this procedure is to provide guidelines for the safe administration of inhaled medications. This policy indicated to explain the procedure to the resident. Administer the medication as follows: Shake the inhaler gently to mix the medication ., remove the cap from the mouthpiece, ask the resident to inhale and exhale deeply for a few breath cycles, on the last cycle, instruct the resident to exhale deeply. Instruct the resident to close his or her lips to form a seal .depress the medication .instruct 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 · Dcited before2025-01-10 · 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 ensure oxygen equipment was monitored, changed, and dated as ordered for two out of five sampled residents (Resident 1 and Resident 34) when: 1. The oxygen tubing for Resident 1 was dated 12/25/24 during an observation on 1/7/25. 2. The oxygen bottle for Resident 34 was empty, not full of bubbling water and dated 12/1/24, and the oxygen tubing for Resident 34 was dated 12/25/24. This failure had the potential to cause discomfort, and the spread of infection to the residents, staff, and visitors. Findings: 1. A review of the facility's policy revised 10/2010, titled, Oxygen Storage and Use, indicated the purpose of this policy is to provide safe storage and use of oxygen equipment. A review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare of the digestive system, a colostomy (an opening for bowel elimination), diabetes, Chronic Pulmonary Obstructive…

    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 · D2025-01-10 · 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 to document behaviors for an antipsychotic (medication used for moods and behaviors to treat mental illness) medication used for one of three sampled residents (Resident 31). This failure had the potential to not identify an increase in behaviors, identify new interventions needed, and a change in condition that should be reported to the physician for medication management. Findings: A review of the facility's policy revised 12/2016, titled, Antipsychotic Medication Use, indicated residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. A review of the facility's policy revised 12/2016, titled, Behavioral Assessment, Interventions, and Monitoring, indicated behavioral symptoms will be identified using…

    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 · E2023-10-12 · 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

    Based on interview, record review and facility policy review, it was determined that the facility failed to ensure an advance directive was on file for 2 (Resident #26 and Resident #28) of 4 residents reviewed for advance directives. Findings included: A review of a facility policy titled, Advance Directives, revised April 2013, revealed, 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 5. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline. 1. A review…

    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 · E2023-10-12 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure that before bed rails were installed, residents were assessed for risk and evaluated for appropriate alternatives and that informed consent for bed rail use was obtained from the resident or their representative for 3 (Residents #42, #35, and #27) of 4 residents reviewed for bed rail use. Findings included: A review of the facility policy titled, Bed Safety, revised 12/2007, revealed, 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 7. After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g. [for example], if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-12 · 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 observations and interviews, the facility failed to offer or provide assistance to residents with hand hygiene prior to meal service. This was observed on two of four days of the survey on two of two halls (East Hall and South Hall) for which meal service was observed. Findings included: Review of a facility policy titled, Policies and Practices - Infection Control, revised 07/2014, revealed, 1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. The policy also indicated, 3. The Quality Assurance and Performance Improvement Committee, through the Infection Control Committee, shall oversee implementation of infection control policies and practices, and help department heads and managers ensure that they are implemented and followed. 1. During an observation on 10/10/2023 at 12:48 PM, Certified Nursing Assistant (CNA) #12…

    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 · D2023-10-12 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and facility policy review, the facility failed to develop a baseline care plan that included the minimum healthcare information to properly care for 1 (Resident #195) of 3 residents reviewed for baseline care plans. Findings included: Review of a facility policy titled, Care Plans-Preliminary, revised 08/2006, revealed, A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. 1. To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within 24 hours of the resident's admission. 2. The Interdisciplinary Team will review the Attending Physician's order (e.g. [for example], dietary needs, medications, and routine treatments, etc. [et cetera]), and implement a nursing care plan to meet the resident's immediate care needs. Review of an admission Record revealed the facility admitted Resident #195 on 09/12/2023 with diagnoses that included atrial fibrillation (an irregular heart rhythm), 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, interviews, and facility policy review, the facility failed to ensure the care and services related to oxygen use were addressed on the comprehensive care plan for 1 (Resident #253) of 3 residents reviewed for respiratory care. Findings included: A review of a facility policy titled, Care Planning-Interdisciplinary Team, revised in 02/2014, specified, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). A review of an admission Record indicated the facility re-admitted Resident #253 on 10/03/2023 with diagnoses that included a history of pulmonary embolism and dependence on supplemental oxygen. A review of a 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/06/2023 revealed Resident #253 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · 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

    Based on record review, interviews, and facility policy review, the facility failed to provide wound treatments as ordered by the physician for 1 (Resident # 26) of 3 sampled residents reviewed for wound treatment. Findings included: A review of a facility policy titled, Medication and Treatment Orders, revised 02/2014, revealed, Orders for medications and treatments will be consistent with principles of safe and effective order writing. A review of an admission Record revealed the facility admitted Resident #26 on 06/24/2022 with diagnoses that included squamous cell carcinoma of skin, generalized muscle weakness, and vitamin deficiency. A review of Resident #26's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2023, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident required applications of ointments and medications to the skin. Review of Resident #26's care plan, dated as initiated 05/02/2023 and revised 05/25/2023, revealed the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · 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

    Based on observations, record review, interviews, and facility policy review, the facility failed to follow up on a recommendation from an orthopedic physician for the use of a left-hand splint for 1 (Resident #42) of 1 sampled resident reviewed for range of motion and mobility. Findings included: A review of a facility policy titled, Contracture Prevention, dated 09/01/2008, revealed, It is the policy of the facility to implement interventions to prevent the onset of contractures and to provide interventions to prevent worsening of contractures for residents admitted with contractures. The policy also indicated the following: - 2. If the resident has contractures or is at risk for contractures, a therapy screening may be requested for measurement and treatment planning. - 7. Rehabilitation staff shall document all interventions in the medical record and communicate new interventions to the IDT [interdisciplinary team]. - 9. Social service staff shall assist the resident with obtaining assistive devices as needed and in adapting to new/altered lifestyles. A review of an 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 · Dcited before2023-10-12 · 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

    Based on observations, interviews, record review, and facility policy review, the facility failed to ensure respiratory equipment was stored properly for 2 (Resident #9 and Resident #195) of 3 residents reviewed for respiratory care. Findings included: Review of a facility policy titled, Oxygen Storage and Use, dated 10/22/2010, revealed, Purpose: to provide safe storage and use of oxygen. The policy indicated, 10. The oxygen cannula, mask, etc. [et cetera] shall be stored in a plastic bag when not in use. 1. Review of an admission Record revealed the facility admitted Resident #9 on 09/14/2022 with diagnoses that included chronic obstructive pulmonary disease (a group of lung conditions that make breathing difficult), hypertension (high blood pressure), and Alzheimer's disease. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/24/2023, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required limited assistance 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interviews, and facility document review, the facility failed to ensure laboratory testing was provided as ordered for 1 (Resident #42) of 5 sampled residents reviewed for unnecessary medications. Findings included: A review of an undated facility document titled, Two Easy Steps to Schedule Labwork, revealed, Step 1: Fill out a Laboratory Requisition. Fill out the lab requisition by completing the box in the top right-hand corner and marking the tests to be done. Step 2: Place the Requisition in the Lab Book. The Lab Book has tabs for days 1-31 and the months of the year. For a routine blood draw: place the order under the tab for tomorrow's date. If the draw is to be done in a future month, place the requisition under the tab that corresponds with the month that the blood draw should be done. The Frequently Asked Questions section of the document indicated, How do I track what was done? The test log in the front of the Lab Book shows exactly what was drawn, and the initials of the person who did the draw. You can check to make sure testing was done by…

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

    Administration Deficiencies · Deficient, Provider has date of correction

“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

$31,757 in federal fines across 7 penalties.

  • $4,587 — penalty dated 2023-10-02
  • $4,587 — penalty dated 2023-09-25
  • $4,587 — penalty dated 2023-09-18
  • $4,587 — penalty dated 2023-09-11
  • $4,587 — penalty dated 2023-09-05
  • $4,587 — penalty dated 2023-08-28
  • $4,235 — penalty dated 2023-08-21

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to PRATAP PODDATOORI — 6 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 53.5+0.5 vs chain
Health inspection 3 of 53.2-0.2 vs chain
Staffing 4 of 53.8+0.2 vs chain
Quality measures 5 of 54.2+0.8 vs chain
The other 5 homes this chain runs (chain average 3.5★, 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
PODDATOORI, PRATAPIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 02/17/2006
HYCARE INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/07/2006
ANDRES, NORMAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/17/2006
ATKINS, NICOLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/19/2012
BROWER, ZOILITAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/25/2013
COBB, RUSSELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/13/2006
DAVIS, ALICIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/28/2025
GARRISON, JAREDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
GUERRERO, SYLVIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2022
GUTIERREZ, DIANEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/22/2007
KISSINGER, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/04/2021
MCDONALD-SEABOAT, AMBERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/26/2024
MCGREGOR, TERRANCEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/17/2006
PADANIA, HILDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/16/2025
PROVO, MARSHAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/20/2008
SANGUENZA, KIMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
VARGAS, ADRIANAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/19/2018

CMS files one row per role, so the 36 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$7.0M
Net patient revenuemost recent cost report
+6.4%
Operating marginrevenue minus expenses
$877K
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 65%Medicare 26%Other / private 9%

This home reported $877K paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$372per resident / day
operating cost
$11,306per month
≈ monthly operating cost
$397per 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 056274. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-23, 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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