Redding Post Acute
1836 Gold Street, Redding, CA 96001 · For profit - Limited Liability company · 89 certified beds · (530) 241-6756 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (65%) runs well above the national median (45%)
- about 17% of its spending goes to commonly-owned related companies
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.9% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.4% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.4% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.0% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.6% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 17.4% | 9.8% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 22.9% | 13.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.1% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.1% | 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 table | 12.7% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.3% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.6% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 18.2% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.73 | 2.25 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.96 | 1.57 | 1.80 | better |
‡ 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.
61.0% 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 207 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.7% 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 149 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.0%CMS range 54.4–67.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.8%CMS range 9.6–16.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 55.7% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 59.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 42.3% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 98.8% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 90.7% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 1.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.1%CMS range 4.8–12.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 89 beds and averages 82.2 residents a day — about 92% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.47 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.21 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.69 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.94 hrs/resident/day on weekends vs 4.69 on weekdays — 16% thinner on weekends. RN hours go from 0.24 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 65% is well above 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
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.
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.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · Fcited before2026-02-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 food safety requirements regarding a clean and sanitary kitchen environment for food preparation for all residents who consumed food prepared by the kitchen when:1.The perimeter of the kitchen's walls at the height of the counters and below including pipes, drains, electrical coverings, and flooring were spackled with a filth buildup of food particles and adhered grime.2.The paint was chipped, peeling and worn out on walls, sink, and around flooring.3.The exterior of the stove/oven was unclean with cooked on grime.4.Rolling dollies with buckets of kitchen supplies were dirty with black filth.5.The walk-in refrigerator's flooring was found to be buckled and uneven with a vein of rust expanding down the un-joined seam of the flooring, and when cleaned the rust material puddled from under and between the seam spreading on the flooring.These failures had the potential to incite harmful growth of unhealthy microorganisms resulting in food borne illness amongst the residents that consume products produced…
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.
- Potential for harm · E2026-02-20 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 a safe environment for all residents who use the shower room when a spray bottle of bleach cleaner solution was observed in shower rooms one and two on wing three within unlocked cabinets above the toilets amongst toiletry essentials.This failure had the potential to result in physical injury and negatively impact the overall health for residents utilizing the common space.During a review of the facility's policy and procedure titled, Homelike Environment, dated February 2021, indicated, Residents are provided with a safe.environment.During a review of the facility's policy and procedure titled, Safety and Supervision of Residents, dated Revised July 2017, indicated, Resident safety.and assistance to prevent accidents are facility wide priorities.During an observation on 2/17/26 at 2:00 pm, on wing three, shower rooms one and two were observed to have spray bottles of bleach in unlocked cabinets above the toilet, mirroring one from the other. No lock was visually present or available.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.
- Potential for harm · D2026-02-20 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 observation, interview, and record review, the facility failed to ensure one of six residents sampled (Resident 36), right to a dignified existence was protected when her eyeglasses were not clean.This failure could have resulted in a decrease in Resident 36's vision and emotional well-being.Findings:Review of a facility policy titled, Resident Rights revised October 2025, indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence.Review of Resident 36's medical record indicated that she was admitted to the facility on [DATE] with diagnoses including muscle weakness, and difficulty walking.Review of Resident 36's Minimum Data Set (MDS is a federally mandated assessment tool that measures the health status in nursing home residents) section B (part of MDS pertaining to vision) dated 1/8/26 indicated that Resident 36 wore glasses. Review of Resident 36's MDS Brief Interview for Mental Status…
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.
- Potential for harm · D2026-02-20 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the care plan was revised for one of 18 sampled residents (Resident 6) when the care plan did not include the use of TED hose (tight socks that prevent swelling in the legs).This failure had the potential to cause severe leg swelling, delayed healing and an increased risk of blood clots, which could place this resident at risk for negative clinical outcomes.During a review of the facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, dated April 2009, indicated, goals and objectives are reviewed and/or revised: when the resident has been readmitted to the facility from a hospital or rehabilitation stay.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated March 2022, indicated, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including which professional services are…
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.
- Potential for harm · Dcited before2026-02-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the safe storage of medications for two of five residents sampled (Resident 64 and Resident 85) when:1. Resident 64's medications from home were stored in paper bags in a cabinet in the medication room (a locked room in a healthcare facility used to store, organize, and prepare medications).2. Resident 85's medication was stored loose in a medication cup (a small, disposable cup used for measuring and administering medications) in the medication cart (a wheeled cart used in healthcare to store, medications, and supplies).These failures could have resulted in lost medications or medication errors for Resident 64 and Resident 85.Findings:1.Review of a facility policy titled, Medications Brought to the Facility by the Resident/Family revised April 2007, indicated The facility shall ordinarily not permit residents and families to bring medications into the facility.Review of Resident 64's medical record indicated that she was admitted…
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.
- Potential for harm · Dcited before2025-03-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up and promptly report the results of an x-ray for one of three sampled residents (Resident 1) who were sampled due to falls in the facility when Resident 1 fell on her knee and her physician ordered an x-ray and the facility did not recognize they had not received the x-ray results for two days. This resulted in Resident 1 experiencing unnecessary severe left knee pain and a delay in treatment for two days due to a broken bone. This delay in treatment had the potential for Resident 1 to experience ongoing severe pain and negatively impact her physical, emotional, and psychosocial well-being. Findings: Review of a facility policy titled,Change in a Resident's Condition or Status dated July 2024, indicated 1. The nurse will notify in a reasonable timely manner the resident's attending physician or physician on call when there has been a(an): e. need to transfer the resident to a hospital/treatment center. Review of admission records for Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-17 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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 protect the rights for one of three sampled residents (Resident 1) when Resident 1 did not receive a written notice of a proposed room change. This failure resulted in Resident 1 experiencing distress, frustration and the feeling of not having control over anything in her life. Findings: A review of the facility's policy titled Room Change/Roommate Assignment revised March 2021, indicated Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., [example] residents and their representatives) is given a notice of change prior to the transfer. A review of Resident 1's admission Record (undated), indicated she was admitted [DATE] with diagnoses that included a fracture of the right leg, history of falling, and pain. A review of Resident 1's admission Minimum Data Set (MDS, a clinical assessment) dated 11/13/24, indicated a Brief Interview for Mental Status (BIMS, an assessment of mental capacity)…
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.
- Potential for harm · D2024-11-21 · tag F0641 — isolatedEnsure each resident receives an accurate 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 Minimum Data Set (MDS) assessments were accurate for 2 (Resident #65 and Resident #72) of 19 sampled residents. Findings included: During an interview on 11/20/2024 at 10:16 AM, the Director of Nursing (DON) indicated the facility did not have a policy on MDS accuracy. 1. An admission Record revealed the facility admitted Resident #72 on 10/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, major depressive disorder, anxiety disorder, and post-traumatic stress disorder. An admission MDS, with an Assessment Reference Date (ARD) of 10/19/2024, revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed that the resident was not considered by the state Level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness and/or intellectual disability or a related condition. A letter from the California Department of Health 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.
- Potential for harm · D2024-11-21 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview, record review, and facility policy review, the facility failed to initiate a Level I Preadmission Screening and Resident Review (PASRR) for a resident who received a psychiatric diagnosis, prior to readmission, for 1 (Resident #16) of 3 residents reviewed for PASRR. Findings included: An undated facility policy titled, PASRR Completion Policy revealed, The Center will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. An admission Record revealed the facility originally admitted Resident #16 on 01/10/2024 and re-admitted the resident on 08/01/2024. According to the admission Record, the resident had a medical history that included diagnosis of dementia with behavioral disturbance. A Medicare 5-Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, facility document review, and facility policy review, the facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASRR) for 1 (Resident #24) of 3 residents reviewed for PASRR. Specifically, Resident #24 had a diagnosis of schizophrenia that was not captured on their Level I PASRR. Findings included: An undated facility policy titled, PASRR Completion Policy, indicated, The Center will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. An admission Record indicated the facility admitted Resident #24's on 06/03/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia with an onset date of 06/03/2024 and major depressive disorder with an onset date of 06/03/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the 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.
Show the remaining 7 citations
- Potential for harm · Dcited before2024-09-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of six residents who were sampled for quality of care (Resident 1), received care that was in accordance with professional standards and consistent with Resident 1's preferences and goals and at the level of assistance he needed. Resident 1 was admitted for Comfort Care (end of life care) on the afternoon of 9/14/24, and requested not to be put into a brief (adult diaper). During the night shift on 9/14/24, Certified Nursing Assistant (CNA) D had left Resident 1 in a soiled night gown, soiled brief, wet sheets, and the television (TV) in his room blaring and had not assisted Resident 1 in eating his supper. Resident 1 was found on 9/15/24 around 6:45 am, by his Family Member (FM) A and CNA C, in a soiled and soaking wet brief and hospital gown with dried brown rings on his bed sheets and the TV blaring. These failures resulted in Resident 1 having a horrible experience and lack of sleep and he left the facility that morning and returned…
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.
- Potential for harm · Fcited before2022-01-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 and interview, the facility failed to ensure food was prepared in a clean sanitary manner. This had the potential to cause food borne illnesses to the residents. Findings: During an observation on 1/25/22 at 10:15 am, the trash can in the food prep area had a lid, without foot controls, so staff had to use their hands to open and close the lid. The facility cook (FC) opened the trash can lid with her hand, threw away trash, closed the trash can lid with her hand, then picked up spices and continued in her meal prep, without hand hygiene. During an interview on 1/25/22 at 10:20 am, this was discussed with the Dietary Services Manager (DSM)who agreed they needed a trash can with a lid that could be opened with foot controls. He said he would talk to the Administrator about getting a new one. During an observation on 1/25/22 at 2:40 pm, the gas line-valve next to the stove/oven was covered with dust and what appeared to be spider webs (see pictures). This was immediately showed to the DSM who confirmed the observation and said he would make sure it was cleaned…
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.
- Potential for harm · F2022-01-27 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 establish and maintain an infection prevention and control program to provide a safe, and sanitary environment and to help prevent the transmission of infections with the census of 54 when: 1. Two out of two medication carts (a mobile cart used to store the medication and supplies for quick access for administration to residents) had unclean pill cutter (a small device that splits individual pills) shared among residents. 2. Licensed Nurse 4 (LVN 4) did not follow infection control practices when entered resident's rooms without following facility's policy on Transmission Based Disease (or same as TBP or Transmission Based Precaution used to help stop the spread of germs from one person to another by using protective measures such as putting gloves, sanitizing hand and putting on the gown and mask) before entering the rooms on three resident's rooms (Resident 41, Resident 23, Resident 36) with census of 54. 3. The shared glucometer (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.
- Potential for harm · Ecited before2022-01-27 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 house supply medications in the Central Supply Storage room (a storage room in the facility for non-prescription medications) were stored at a safe controlled room temperature in one out of three medication storage areas and a census of 54 residents. This failure could potentially cause medication to become ineffective if stored outside the manufacturer's recommended temperature guidelines. Findings: During an observation and tour of the facility's Central Supply Storage (a room that stored medical supplies and non-prescription or Over the Counter [OTC] medications) on 1/24/22 at 9:05 AM accompanied by LVN 1, the small storage room stored shelves of OTC medications, medical supplies, and multiple computer wiring's that served the facility's computer needs. The small storage room's temperature was warm upon entrance to the room. LVN 1 confirmed the warm temperature while standing in the unvented storage room. Further observation with LVN 1, it was confirmed the facility did not monitor room temperature…
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.
- Potential for harm · D2022-01-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure their fall protocol, including updating the care plan and implementing interventions in the care plan, was completed to prevent falls, for one of four sampled residents, with a history of falls (Resident 4). This had the potential to result in a fall with serious injury. Findings: A review of Resident 4's record indicated she was admitted on [DATE] with diagnoses that included dementia, diabetes, and muscle weakness. Resident 4 had a falls care plan started upon admission. It had been updated to include non-slip socks while in bed, and non-slip socks and shoes when out of bed. Resident 4 had an unwitnessed fall on 9/1/21 and 11/30/21. Nursing progress notes, dated 9/1/21 at 10:26 am, indicated the resident had ambulated (walked) to the restroom without assistance and fell, landing on the right side of her body in front of the bathroom door. An assessment was done and she moved all extremities without pain. On 9/1/21 at 10:34 am, 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.
- Potential for harm · D2022-01-27 · tag F0711 — isolatedEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
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 resident's symptoms and distress were addressed on timely manner when existing nursing treatment and or medication did not improve the symptoms in one out of 17 sampled residents (Resident 52). This failure could contribute to unsafe care and/or resident's comfort level. Findings: During Resident 52's medical record review titled Medication Administration Record (or MAR, a legal drug chart where nurse documented medications administration and monitoring), with date range of 1/1/22 to 1/31/22, the MAR indicated a medication order for Benadryl (or diphenhydramine, a medication used to treat allergy symptoms such as itching) as follow: Benadryl Allergy Tablet 25 mg (mg is a measure of unit), [diphenhydramine HCL]: Give 25 mg by mouth every 6 hours as needed for itching- Order Date- 6/25/21. Further review of the MAR indicated Benadryl medication was administered up to 3 times per day for itching. During review of Resident 52's nursing Care Plan (Care Plan was a nursing record of how to identify and address resident'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.
- Potential for harm · D2022-01-27 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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
Based on interview, and record review the facility failed to ensure high risk anticoagulant medication (or blood thinner medication that may cause bleeding) was monitored on daily basis by nursing staff for possible adverse effects of the medication in one out of 17 sampled residents (Resident 28). This failure could result in unsafe medication use in the facility. Findings: During a review of Resident 28's medical record titled Medication Administration Record (or MAR, a legal drug chart where nurse documented medications administration and monitoring), the MAR indicated a doctor's medication order for rivaroxaban (or Xarelto, a blood thinner or anticoagulant medication) as follow: Rivaroxaban Tablet 20 mg (mg is a measure of unit); Give 20 mg by mouth in the evening for prevention of DVT/PE (DVT stands for Deep Vein Thrombosis which was blood clot in the leg's arteries and PE stands for Pulmonary Embolism which was blood clot in the lung; both conditions could cause resident harm); order date: 8/14/2021 Review of the Resident 28's nursing Care Plan (Care Plan correctly identified…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to WEST HARBOR HEALTHCARE — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.3 | +0.7 vs chain |
| Health inspection | 4 of 5 | 3.1 | +0.9 vs chain |
| Staffing | 2 of 5 | 3.5 | -1.5 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 7 homes this chain runs (chain average 3.3★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| VALLEY CAPITAL INVESTMENTS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | since 01/01/2017 |
| WEST HARBOR HEALTHCARE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 90% | since 01/01/2017 |
| GALBASINI, KEVIN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 45% | since 01/01/2017 |
| GILL, DANIEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 45% | since 01/01/2017 |
CMS files one row per role, so the 8 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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
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
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.
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 055510. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-20, 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.