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Veterans Home Of California - Redding

3400 Knighton Road, Redding, CA 96002 · Government - State · 60 certified beds · (530) 224-3300 Medicare & Medicaid certified

Call the home — (530) 224-3300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$8,278 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,278 in federal fines (most recent 2025-08-20)

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3455 Knighton Road
Pharmacy
Rite Aid2.1 mi
6424 Westside Rd · (530) 243-3616 · Call to confirm hours
Grocery
7036 Westside Rd Ste 103 · (530) 246-9044 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
7918 Churn Creek Rd · (530) 223-0515

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

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

Trend — is this home getting better or worse?

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

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.0%10.2%15.4%typical
Long-stay residents who lose too much weight2.7%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.7%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury6.7%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened13.5%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication1.3%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers5.4%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control13.7%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 table23.7%12.0%17.1%worse
Long-stay hospitalizations per 1,000 resident days0.852.251.67better
Long-stay outpatient ER visits per 1,000 resident days0.641.571.80better

* 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.

0.44U.S. median 0.31
Therapy hours / resident / day
0.30hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

2.33
RN hours/ resident / day
0.68
LPN hours/ resident / day
2.91
Aide hours/ resident / day
5.92
Total nurse hours/ resident / day
1.57
RN hoursweekends
38.9%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 39.9 residents a day — about 66% occupied, or roughly 20 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.33 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.91 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 5.00 hrs/resident/day on weekends vs 6.29 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 2.64 to 1.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as 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

4
deficiencies at the latest standard inspection (2026-04-23)
6
at the previous standard inspection (2025-04-10)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Actual harm · G2025-08-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to reassess fall risk factors and update the care plan interventions for 1 of 3 sampled residents (Resident 2), who was identified as being at high risk for falls. This failure resulted in Resident 2's unwitnessed fall, transfer to the acute care hospital for evaluation and treatment, and subsequent admission due to several broken ribs and a broken right collarbone on 8/3/25 (refer to Intake 2581256).Findings: During a concurrent observation and interview on 8/20/25 at 11:35 AM with Resident 2 in his room, Resident 2 was observed with multiple purplish black discolorations on the right side of his trunk, right side of his head/face, and some small, scattered purplish black discoloration on his right arm. Resident 2 was alert and oriented to person, place, and time. However, Resident 2 got short of breath easily and was drowsy during the interview. Resident 2 stated he did not recall what happened on 8/3/25 when he fell and sustained his…

    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 before2026-04-23 · 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 store and label pasteurized eggs in accordance with professional standards for food service safety, and facility policy, when an unlabeled tray containing 18 pasteurized eggs was found in the walk-in refrigerator outside of its marked container.This failure had the potential to expose medically fragile residents to food contamination, increasing the risk of foodborne illness for all 39 residents who eat meals prepared in the kitchen.During an observation on 4/20/26 at 2:20 p.m. in the Main Kitchen's walk-in refrigerator a tray containing 18 pasteurized eggs was observed left outside of its marked container. The tray did not have a label indicating the received-on date or the use by date.During an interview on 4/20/26 at 2:31 p.m. with Stock Clerk (SC) 1, SC1 was unable to identify a used by date labeled on the tray of eggs.During an interview on 4/20/26 at 2:34 p.m. with [NAME] (C) 1, C1 was unable to identify a used by date labeled on the tray of eggs.During an interview on 4/23/26 at 3:11 p.m. with the Food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 proper grooming by ensuring fingernail care for one of twelve sampled residents (Resident 7), in accordance with the facility policy titled, Activities of Daily Living.This failure had the potential to increase the risk of infection for Resident 7.During a review of Resident 7's admission Record, dated 12/16/25, the admission Record, indicated Resident 7 was admitted to the facility with diagnoses of osteoarthritis (breakdown of cartilage) and tremor (involuntary shaking).During a concurrent observation and interview on 4/20/26 at 2:31 p.m. with Resident 7, in the facility hallway, Resident 7 was seated in his wheelchair with his fingernails exposed. Resident 7's fingernails were long. Resident 7 stated he wanted his nails trimmed and staff did not consistently perform nail trimming.During a concurrent observation and interview on 4/20/26 at 4:13 p.m., with Certified Nursing Assistant (CNA) 1, in the facility hallway, Resident 7 was seated in his wheelchair with his fingernails exposed. CNA 1…

    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 · D2026-04-23 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure expired medication was not available for use when two vials of Lidocaine HCL (used to rapidly numb specific body areas for medical procedures by blocking nerve pain signals) were stored in the emergency kit beyond their expiration date.This failure had the potential to place residents at risk of receiving expired medication, which may lead to harmful side effects or reduced effectiveness.During a concurrent observation and interview on [DATE] at 9:10 a.m. with the Director of Nursing (DON) inside the medication room, the emergency kit contained two vials of Lidocaine HCL which had an expiration date of 3/2026. The DON confirmed the medication vials were expired. The DON stated that pharmacy and nursing staff should check the emergency kit for expired medication.During an interview on [DATE] at 10:24 a.m. with the DON, the DON stated, medication should not be expired for resident safety and for drug efficacy.During a review of the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-23 · 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 maintain an effective infection control program when one of twelve sampled residents (Resident 20) indwelling catheter (a tube placed in the body to drain and collect urine from the bladder) bag was touching the floor.This failure had the potential to cause cross contamination and increase the risk of infection for Resident 20.During a concurrent observation and interview on 4/20/26 at 5:55 p.m., with Registered Nurse (RN) 1 in the facility hallway, Resident 20 was observed seated in a wheelchair self-propelling in the hallway. A urinary catheter drainage bag was secured to the lower portion of the wheelchair however, the catheter tubing was touching the floor. RN 1 confirmed the observation and stated the tubing should not be in contact with the floor due to infection control concerns.During a review of Resident 20's admission Orders (AR) dated 12/2/25, the AR indicated, Resident 20 required a indwelling catheter for a diagnosis of bladder outlet obstruction (blockage at the base of the bladder).During an…

    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 · E2025-08-20 · tag F0697 — failed to manage pain — pattern
    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 the pain medication was administered as prescribed for Resident 1. This failure had the potential to result in uncontrolled pain management and adverse outcomes for Resident 1 (refer to Intake 2573274).Findings: During a review of Resident 1's face sheet, the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included heart failure, metastatic (the spread of cancer cells from the place where they first formed to another part of the body) prostate cancer, and muscle weakness. During a review of the facility's policy and procedure titled, Medication Administration, General Guidelines (SNF), dated 4/21/25, the P&P indicated, Medications are administered only by nursing . 1. As Ordered: Medications are administered in accordance with and with orders of the prescriber. During a concurrent interview and record review on 8/20/25 at 10:23 AM with the LVN 1, the physician order for Oxycodone (narcotic pain…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-10 · 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 observations, dietary and leadership staff interview and departmental document review the facility failed to ensure food handling practices were consistently carried out in accordance with food safety standards when: 1. There were lapses in cooldown monitoring of foods associated with foodborne illness and 2. One staff member was chewing gum during food production activities. These failures had the potential to result in foodborne illness and cross-contamination for the facility's residents. Findings: 1. Potentially Hazardous Foods (PHFs) are those foods capable of supporting bacterial growth associated with foodborne illness. Protein based foods such as meat, beans and canned tuna are considered PHFs and require time/temperature control for food safety during periods of preparation, storage and distribution (US Department of Agriculture [USDA], Food Code, 2022). Cooked foods requiring time/temperature control for safety food shall be cooled: within 2 hours from 135ºF (degrees Fahrenheit) to 70°F and within a total of 6 hours from 135ºF to 41°F or less. Food shall be cooled…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-10 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that internal and external medications were stored separately for 2 of 2 medication storage areas observed. This failure had the potential to cause cross-contamination and medication administration errors. Findings: On 04/07/25, at approximately 3:20 p.m., during a tour of the medication storage areas located in the Clamath and [NAME] nursing stations, it was observed that internal-use medications were stored directly adjacent to external-use products without appropriate separation. Specifically, oral medications such as [NAME] & Thrive Loperamide tablets, Glucosamine Sulfate 500 mg capsules, and Calcium Citrate tablets were stored next to external-use items including Fleet Saline Enema, GenTeal Tears Lubricant Eye Drops, Refresh Plus Eye Drops, and Major Ear Drops (Carbamide Peroxide 6.5%). No physical barrier, labeled bin, or designated shelving was in place to distinguish internally administered medications from those intended…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-10 · 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 observation, interview, and record review, the facility failed to ensure two of 17 sampled residents (Resident 9 and Resident 19) were free of unnecessary psychotropic medications (drugs that affect brain function, mood, thoughts, or behaviors) when: 1. Staff did not implement non-pharmacological interventions (treatments that do not involve medication prior to administering psychotropic medications) for Resident 19. 2. Staff failed to implement behavioral monitoring related to the use of psychotropic medications for Resident 9. These failures had the potential to result in unecessary drug administration for Residents 9 and 19. Findings: 1. During a review of the Face Sheet for Resident 19, the Face Sheet indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses which included heart failure (the heart can't pump enough blood to meet the body's needs), unspecified atrial fibrillation (heart condition which causes an irregular heartbeat). During an interview on 4/9/25 at 8:28 a.m.,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-10 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, three medication errors were observed out of twenty-eight opportunities, resulting in an error rate of 10%, and involved two separate insulin administrations and one nasal spray medication for Resident 3. These deviations from proper technique posed a risk for suboptimal therapeutic outcomes. The failure to adhere to manufacturers' instructions for insulin and nasal spray administration not only violates professional standards of practice but also increases the risk of therapeutic failure and resident harm. Findings: 1. According to the manufacture's insert instructions for insulin (#1), the dose button must be held in and the needle kept in the skin for at least five seconds to ensure full dose delivery. Similarly, manufacture's insert instructions for insulin (#2) once the dose button was pressed, the needle should remain under the skin for…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-10 · tag F0801 — isolated
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, leadership interview and dietary department document review the facility failed to ensure sufficient staff were employed as evidenced by the lack of a full-time qualified position to supervise and manage the day-to-day operations of the skilled nursing dietetic services. Failure to ensure sufficiently qualified staff may result in dietetic services that are inconsistent with professional standards of practice placing 35 residents at risk for potential food related medical complications. Findings: Per California Code of Regulations, Title 22, Chapter 3, dietetic services is defined as the provision of safe, satisfying and nutritionally adequate food for patients with appropriate staff, space, equipment and supplies. Additionally, California Health and Safety Code, 1265.4 describes the staff qualifications for the day-to-day management of dietetic services in a skilled nursing facility. The Health and Safety Code describes, in the absence of a full-time Registered Dietitian with supervisory responsibilities for dietetic services, the licensed facility shall…

    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 10 citations
  • Potential for harm · D2025-04-10 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a complete and accurate medical record when consent for the use of psychotropic medication (drugs that affect brain function, mood, thoughts, or behaviors) was not documented in the medical record for one of 12 sampled residents (Resident 19). This failure had the potential for Resident 19 to receive psychotropic medication that the resident did not consent to leading to unwarranted side effects. Findings: During a review of the Face Sheet, for Resident 19, the Face Sheet, indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses which included heart failure (the heart can't pump enough blood to meet the body's needs), unspecified atrial fibrillation (heart condition which causes an irregular heartbeat). During a concurrent interview and review of Resident 19's record on 4/8/25 at 2:53 p.m., with the Director of Nursing (DON), the following physician's orders were reviewed: On 3/24/25, the physician ordered…

    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 · D2024-09-18 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 respect 1 of 3 sampled residents (Resident 1) right to personal privacy when Resident 1's bank account statement was opened and viewed by facility staff. This failure resulted in unauthorized access to Resident 1's personal privacy. Findings: During a concurrent observation and interview with Resident 1 on 9/17/2024 at 9:25 AM in the day hall of the facility, Resident 1 was oriented to person and place. Resident 1 stated her son and daughter took care of her finances. During a review of Resident 1's Face Sheet, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain.) Furthermore, Resident 1's Face Sheet indicated the Resident 1's Son had the Durable Power of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-04-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions in the food service department when: 1. Equipment was not replaced when considered unsafe, 2. Foods were found uncovered in the storage area, 3. Foods were not labeled appropriately, 4. Unsafe food was not discarded. These failures had the potential to expose residents to food contamination and foodborne illnesses (sickness by consuming contaminated food or drinks) for a population of forty-one residents who consume food from the kitchen. Findings: 1. During a concurrent observation and interview on 4/22/24 at 8:21 a.m. with the Dietetics Assistant Director (DAD) in the main kitchen, a can opener was found with metal chipped off the cutting tip. DAD confirmed, the missing metal part of the can opener and acknowledged the metal was likely flaking into the canned food during use. During a concurrent observation and interview on 4/22/24 at 8:31 a.m. with the Food Manager (FM) in the main kitchen, four out of twelve cutting boards were discolored with deep scratches. FM…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-04-25 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure that two out of eight dumpsters were covered for the main and the satellite kitchens. This failure had the potential to attract pests, rodents and spreading bacteria and leading to food contamination for a population of forty-one residents. Findings: During a concurrent observation and interview on 4/22/24 at 9:05 a.m., with the Assistant Administrator (Admin 2), one out of four trash dumpsters for the main kitchen was not covered, exposing trash. Admin 2 confirmed, it should be closed and proceeded to close the two lids. During an observation on 4/23/24 at 10:56 a.m., in the satellite kitchen, one out of four trash dumpsters was not covered, exposing trash. During an interview on 4/24/24 at 2:30 p.m., with the Dietetics Assistant Director (DAD), DAD stated, trash dumpsters need to be closed at all times when not in use, because it can attract rodents or pests to the facility. During a review of the facility's policy and procedure (P&P) titled, Waste Management Program, dated 12/12/23, the P&P…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-25 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for two of four sampled residents (Resident 21 and 26) when: 1. A non-crushable medication, pantoprazole (medication to reduce acid production in the stomach), was crushed and administered to Resident 26 despite manufacturer's guidelines not to crush medication due to delayed release. 2. A non-crushable medication, finasteride (medication to treat enlarged prostate), was crushed and administered to Resident 26 despite facility's guidelines regarding handling of finasteride. 3. Resident 21 was not instructed to rinse his mouth after being administered fluticasone furoate (nasal spray used to treat sneezing, itchy or runny nose), umeclidinium (medication used for chronic obstructive pulmonary disease), and vilanterol inhalation powder (a combination of inhaled medications to treat breathing issues) despite manufacturer guidelines to rinse mouth after use to prevent hoarseness and…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement the plan of care for two of 12 sampled residents (Resident 18 and Resident 25) when: 1. For Resident 18, the care plan intervention Call don't fall signs were not posted, and assistive devices were not within reach. 2. For Resident 25, the care plan intervention Call don't fall signs were not posted, and discontinued assistive devices with signage were present in room. These failures had the potential to result in subsequent falls and serious injuries for Residents 18 and 25. Findings: 1a. During a review of Resident 18's Face Sheet (demographics), the Face Sheet (demographics) indicated Resident 18 was admitted to the facility on [DATE], with diagnoses of left below the knee amputation, right transmetatarsal amputation (surgery to remove part of the foot) and has had frequent falls since admission. During a review of Resident 18's Quarterly MDS, dated [DATE], indicated Resident 18 was able to stand from a sitting position in 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-25 · 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

    Based on observation, interview, and record review, the facility failed to ensure safe monitoring of pharmaceutical medical supplies when four expired filter needles (a needle designed to remove particles, like glass, that might contaminate medication) were found in the injectable Emergency Drug Kit (E-Kit, small supply of medications for emergency situations). This failure had the potential to result in expired and ineffective medical supplies being used for residents and had the potential to result in contaminated medications being injected into residents. Findings: During an observation on 4/22/24 at 10:29 a.m. in the Klamath Unit medication room, there was a sealed orange box labeled, Klamath E-kit. On the exterior of the E-kit, there was a list of contents, including filter needles, and the date for the earliest upcoming expiration date. The kit contained four filter needles, labeled lot #7025483 (code that identifies one batch of a product that is made at the same time) which did not have any expiration date. During an interview on 4/22/24 at 11:39 a.m. with the Pharmacy…

    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 · D2024-01-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to protect Resident 1 from verbal abuse when CNA 1 (certified nurse ' s assistant 1) called Resident 1, you dk, after Resident 1 punched CNA 1 on the chest. This failure resulted in verbal abuse to Resident 1. Findings: During an interview on 12/22/23 at 7:00 p.m. with CNA 3, CNA 3 stated, CNA 1 was assigned to Resident 1 ' s room. CNA 3 continued, CNA 2 and CNA 3 heard a call light ring, and they went to check who was calling. CNA 3 added they saw the light was from Resident 1 ' s room, and she started to walk to Resident 1 ' s room when CNA 2 joined. CNA 3 stated that as she was approaching Resident 1 ' s room, she heard a commotion in the room, so she listened at the door. CNA 3 added, she heard Resident 1 fussing and fighting, then she heard CNA 1 yell, F*ing Dk, to which CNA 2 told CNA 3 that was inappropriate. CNA 3 stated CNA 1 went to get linen for Resident 1 ' s room and CNA 2 and CNA 3 asked CNA 1 to leave the room. CNA 3 added she and CNA 3 took over care for Resident 1 and CNA 1 stayed outside the door. CNA…

    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 · D2023-09-28 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report an alleged abuse incident to law enforcement officials when Resident 1 reported a sexual assault incident in the Skilled Nursing Facility. This failure did not allow for law enforcement officials to conduct an investigation. Findings: During an interview on 9/13/23 at 11:22 p.m. with Standards Compliance 1 (SC 1), SC 1 stated when referring to the section of the policy titled, Will report to in accordance with State law, SC 1 stated We reported to the Ombudsman (resident advocate) and CDPH (California Department of Public Health) Licensing (oversight and monitoring agency for California skilled nursing facilities). SC 1 added, If we found an assault had occurred, we would have reported it to California Highway Patrol (CHP). SC 1 said, Our CHP doesn't want everything reported to them, only the financial and serious injuries. SC 1 stated after Social Worker 1 (SW 1) and SC 1 spoke to the Resident 1, SC 1 stated, We determined he wanted to shower himself. He does not want males to shower him. SC 1 added, The more…

    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 · E2023-09-08 · 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

    Based on interview and record review, the facility failed to follow their Policy and Procedures (P&P) on abuse reporting for two of two sampled residents (Resident 1 and Resident 2), when an abuse allegation was made by a Custodian Worker (CW 1). This failure had the potential of putting residents at risk for harm by not following proper procedures including removing the alleged abuser from patient care, failing to complete proper documentation, and notifying the appropriate agencies. Findings: During an interview on 8/29/23 at 7:15 a.m., with CW 1, CW 1 stated on August 19, 2023, at 08:10 a.m. a Certified Nursing Assistant (CNA 1) was in Resident 1 room and heard the Resident yell at her to get out of his room. CNA refused to leave and forced Resident 1 into his wheelchair to take him to the breakfast area. CW 1 stated CNA 1 then could be heard and seen by everyone verbally agitated and picking on the resident and stated, You are a nasty mean old man to which he replied, No I'm not, go away. CW 1 stated Resident 1 asked CNA 1 to go away multiple times and she just stood there 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.

    Freedom from Abuse, Neglect, and Exploitation 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

$8,278 in federal fines across 1 penalty.

  • $8,278 — penalty dated 2025-08-20

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.

Who owns this facility

Owner / managerTypeRoleShareSince
DEPARTMENT OF VETERANS AFFAIRS OF THE STATE OF CALIFORNIAOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 10/22/2013
KOPPES, JESSICAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/23/2025
KREISHER, TIMOTHYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/22/2024
VOGUS, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2012

CMS files one row per role, so the 9 rows in the source record cover these 4 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.

$12.8M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$803per resident / day
operating cost
$24,407per month
≈ monthly operating cost
$293per day
avg. revenue, all payers

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

What families pay in CA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555891. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-23, 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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