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Vibra Hospital Of Northern California D/P SNF

2801 Eureka Way, Redding, CA 96001 · For profit - Corporation · 32 certified beds · (530) 245-4112 Medicare & Medicaid certified

Call the home — (530) 245-4112 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Feb 2023
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)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2023
  • 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
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Urgent care / clinic
2701 Old Eureka Way · (530) 241-4250 · Call to confirm hours
Pharmacy
2710 Eureka Way · (530) 243-2700 · Call to confirm hours
Grocery
3315 Placer St · (530) 242-0477 · Call to confirm hours
Park
1614 Magnolia Ave · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Short-stay residents who newly got an antipsychotic medication2.0%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine96.8%93.2%79.4%better
Short-stay residents rehospitalized after admission20.5%23.0%22.6%typical
Short-stay residents with an outpatient ER visit10.4%11.2%12.0%better

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.

70.0% 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 373 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

70.0%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
69.6%U.S. median 56.6%
Met the expected recovery
1.14U.S. median 0.31
Therapy hours / resident / day
0.65hours / resident / day
Physical therapy
0.36hours / resident / day
Occupational therapy
0.12hours / resident / day
Speech therapy

Met the expected recovery: 69.6% 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 168 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 1.14 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF70.0%CMS range 65.0–73.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 7.5–11.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge69.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge73.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge72.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge89.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.9%CMS range 4.0–8.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.47
RN hours/ resident / day
2.01
LPN hours/ resident / day
2.60
Aide hours/ resident / day
6.09
Total nurse hours/ resident / day
1.29
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 32 beds and averages 26.4 residents a day — about 82% occupied, or roughly 6 beds typically open. It usually has some room. 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 6.09 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.47 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.60 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 5.23 hrs/resident/day on weekends vs 6.44 on weekdays — 19% thinner on weekends. RN hours go from 1.55 to 1.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

8
deficiencies at the latest standard inspection (2025-05-23)
6
at the previous standard inspection (2024-03-07)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · Fcited before2025-05-23 · 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 food safety and sanitation guidelines were followed when: 1. Time/Temperature Control for Safey (TCS) food, (food that requires specific temperature management to prevent harmful bacteria growth and toxin formation), for residents was not stored at appropriate temperatures in one of one nourishment refrigerators; and 2. The dish machine wash and rinse cycle temperatures did not meet manufacturer's temperature specifications; and 3. Black matter was found on the underside of the top surface of the ice machine storage bin located in the facility kitchen; and 4. A butcher block wooden cutting board was not cleaned with soap and water before being sanitized; and 5. [NAME] discoloration was found on the blending blades of two food processors in the kitchen; and 6. One plastic cutting board and three plastic bowls used for food preparation and food service showed signs of excessive wear. These failures had the potential to cause foodborne illnesses in 30 out of 30 residents who consumed food prepared in the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-23 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a copy of the discharge notice was sent to the Office of the State Long-Term Care Ombudsman (assists with conflict resolution and protection of resident rights) for two out of three sampled residents (Residents 14 and 16). This failure had the potential to violate the resident right to appeal their discharge. Findings: A review of the facility's policy and procedure (P&P) titled, Transfer and Discharge Nursing Services, dated, 1/1/24, indicated, when the residents were discharged from the facility, the residents would be notified in writing. The P&P indicated, The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. A review of the, Clinical Record Abstract, dated 5/21/25, indicated, Resident 14 was admitted to the facility on [DATE] with the diagnosis of type 2 diabetes mellitus (uncontrolled blood sugar levels) with diabetic chronic kidney disease (an organ that filtered out the body's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-23 · 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

    Based on observation, interview, and record review, the facility failed to ensure that medications were administered in accordance with manufacturer's instructions and accepted standards of clinical practice for 3 of 31 medication administration opportunities observed, resulting in a medication error rate of 9.7%. This failure placed residents at risk of reduced therapeutic effect and potential harm. Findings: Review of Resident 217's record titled, Discharge Reconciliation Report, dated 5/21/2025, indicated Resident 217 had an order for MiraLAX; 1 packet (medication used for constipation) daily and Trelegy Ellipta inhaler (used to treat asthma and the management of chronic obstructive pulmonary disease) 1 puff daily. The instructions were to breathe out slowly and then fully inhale the dose while taking a slow deep breath through the mouth and hold breath for 10 seconds or as long as long as comfortable, then breathe out slowly. During an observation at 8:25 am, in Resident 217's room, Licensed Nurse (LN) A was preparing Resident 217's morning medications. LN A mixed the MiraLAX in…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their Self-Catheterization (a procedure where the resident inserts and removes a flexible tube into the bladder and drains urine without the assistance of staff), policy and procedure (P&P) for one of one sampled residents (Resident 13) when: 1. The facility did not maintain adequate self-catheterization supplies; and 2. There was no physician order for Resident 13 to perform self-catheterization; and 3. There was no nursing assessment performed to ensure Resident 13 was able to perform self-catheterization safely. This had the potential to damage the bladder, cause infection, and could cause psychosocial harm. Findings: 1. A review of the facility's P&P titled, Self-Catheterization revised 6/1/24, indicated, the facility would ensure residents that performed self-catheterization were provided with supplies and equipment. A review of the Clinical Record Abstract, dated 5/22/25, indicated, Resident 13 was admitted to the facility on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · 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: 1. Metoprolol injectable vials (intravenous medication use to treat high blood pressure, and heart problems), were not stored and protected according to manufacturer recommendations for 1 of 1 pharmacy storage areas reviewed. 2. The nursing staff discarded MediSense (a brand name) glucose control solution (a solution with a specific known concentration of sugar used to calibrate and check the accuracy of a blood glucose meter) vials, when they expired. This failure had the potential to affect the stability and effectiveness of medications administered to residents and produced inaccurate patient blood glucose test results which could have led to negative clinical outcomes. Findings: 1. During an observation on [DATE] at 11:00 am, in the facility's pharmacy, three injectable vials of metoprolol were stored in a small container directly under an overhead light. The vials were not enclosed in an amber bag, or otherwise shielded from…

    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 · D2025-05-23 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure dietary menus were followed when: 1. [NAME] D did not follow the puree pork recipe; and 2. [NAME] D did not consistently use the required scoop sizes when measuring portions of food. These failures had the potential for under or over nourishment resulting in poor health outcomes for 30 out of 30 residents who received food prepared in the facility kitchen. Findings: A review of the facility's Matrix dated 5/20/25, indicated there were 30 residents residing in the facility who received food prepared in the kitchen. 1. A review of a facility's, Food and Nutrition Services policy titled, Standardized Diets, rev. 01/2025, indicated that regular and therapeutic [specialized] diets are planned to guide patient menu processing, meal production, and preparation. A review of a facility production recipe, undated, for pureed (ground) pork roast specified three ounce servings of pork; the directions indicated that water or stock could be used in the preparation of the recipe, and that the sodium content of the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-23 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 facility document review the facility failed to provide a meal substitute equivalent in nutritive value and food preferences were not honored when: 1. Two of two residents (Resident 367 and Resident 9), received a grilled cheese sandwich as a meal substitute for the lunch meal; and 2. Food preferences were not honored for one of one residents (Resident 7) These failures posed the risk for resident nutritional needs not being met which could lead to unplanned weight loss. Findings: 1. Review of the facility's document titled, Diet Spreadsheet dated 5/21/25, showed for the CCHO (carbohydrate controlled) diet and the Low Potassium (K) diet, the lunch meal entrée was three ounces of pork roast. Review of the facility's document titled, Detailed Menu Nutritional Analysis for day four, menu cycle: Summer Menu showed three ounces of pork roast provided 23 grams (gms, a unit of measure) of protein and 173 kilocalories (calories). Review of the facility's document titled, Grilled…

    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 · D2025-05-23 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained when Certified Nursing Assistant (CNA) F did not perform hand hygiene between resident care. This had the potential to spread infection. Findings: A review of the facility's policy and procedure (P&P) titled, Infection Control, revised 7/1/20, indicated, facility staff would use alcohol-based hand gel upon entering and exiting a resident's room, touching a resident, and, After contact with inanimate objects (bed, curtains, bed rails, etc.) in the immediate vicinity of the patient. During an observation on 5/20/25 at 12:13 pm, CNA F was observed placing a dirty lunch tray into a metal cart. CNA F pulled a pen and paper out of the right leg pocket of her pants, wrote something down, and placed the pen and paper back into the pocket. CNA F walked into room [ROOM NUMBER] and removed a dirty lunch tray and placed it in the metal cart. CNA F pulled a pen and paper out of the right leg pocket 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-05 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a thorough investigation of an allegation of staff to resident abuse was conducted in accordance with the facility's Abuse Policy, for one of three sampled residents (Resident 1). This had the potential to put all residents of the facility at risk for staff to resident abuse. Findings: Review of a facility's policy titled, Abuse Prevention and Management: TCU dated 6/24 indicated, .each resident shall be free from verbal, sexual, physical and mental abuse . , Residents must not be subjected to abuse by anyone, including .staff of other agencies serving the resident , and The Administrator will: 4) Begin the interviewing process of all involved residents, employees and witnesses , and 7) Start a confidential file including: 1) Resident Statement, 2) Employee Statements 3) Witness Statements . Review of admission records for Resident 1, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including high blood pressure…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-14 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to carry out a resident's wishes for end of life treatment when the facility staff performed cardiopulmonary resuscitation (CPR, an emergency life-saving procedure when breathing or heart beat has stopped ), on one of three sampled residents (Resident 1) that chose not to have CPR not be performed. This resulted in Resident 1 receiving CPR and violated her end of life wishes. Findings: A review of the facility's policy titled, CODE BLUE [means someone is experiencing a life threatening medical emergency where their heart stopped or they are not breathing and staff are to respond immediately] reviewed 5/2021, indicated, Section C: A 'CODE BLUE' will be called on all patients who experience a cardiac and/or respiratory arrest unless a DNR [Do not resuscitate means the same as No CPR] order is written on the patient's chart. Resident 1 was admitted to facility on [DATE] with a diagnosis of high blood pressure and congestive heart failure (CHF, when the heart…

    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
Show the remaining 16 citations
  • Potential for harm · Fcited before2024-03-07 · 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 that Food and Nutritional Services staff followed food safety and sanitation guidelines when: 1. Meat was not thawed properly. 2. Hand hygiene was not consistently performed. 3. The dish machine water temperature did not meet the manufacturer specified guidelines. 4. One hand washing sink in the food service area, did not have hot water. 5. Two of three ice machines were not clean. 6. The sanitizing storage process used for wiping cloths was not followed. 7. Hair restraints were not consistently used by kitchen and maintenance staff. 8. Food preparation equipment was not in good working order. 9. Food was stored in a used non-approved storage container. 10. Clean dishware was stored in soiled containers. 11. Two knife holders were not clean. These failures had the potential to increase the risk of food contamination and food borne illnesses, and subject the residents who ate food from the kitchen, to stomach cramps, nausea, vomiting and diarrhea. Findings: 1. Review of a facility policy titled,…

    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 · F2024-03-07 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain essential foodservice equipment in safe operating condition when: 1. The dish machine water temperature did not meet the manufacturer specified guidelines. 2. One hand washing sink in the food service area did not have hot water. 3. One of three ice machine storage bins was not cleaned per manufacturer specification. These failures had the potential to increase the risk of food and ice contamination, and subject the residents who ate food or used ice from the facility's kichen, to food borne illnesses such as stomach cramps, nausea, vomiting and diarrhea. Findings: 1. The National Sanitation Foundation (NSF) guidelines (instructions) posted on the facility dishwashing machine indicated that the minimum wash water temperature must be 130 degrees Fahrenheit (F, a unit of measuring temperatures), and the minimum rinse water temperature must be a minimum of 130 degrees F. Review of a facility policy titled, Physical Plant 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-07 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that their facility cooks (FC), were trained to safely prepare food and adhere to sanitation requirements in the kitchen when: 1. FC3 did not thaw chicken in accordance with their food safety policy; and 2. FC1 did not perform hand hygiene after removing gloves; and 3.FC1 did not have knowledge of how to properly conduct manual dishwashing procedures, (when dishes are washed in a sink by hand, instead of in a dishwasher). These failures had the potential to increase the risk of food contamination with bacteria and subject the residents to food borne illness such as stomach cramps, nausea, vomiting and diarrhea. Findings: 1. Review of a facility provided record titled, Performance & Goal Review Form dated 2/28/24, indicated that the facility's Certified Dietary Manager (CDM), determined FC3 was compliant with all facility policies. Review of a facility provided record titled, Job Description and Competencies indicated facility cooks would complete a California approved food handling course, maintain…

    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 · D2024-03-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, this requirement was not met when a Certified Nursing Assistant (CNA 1) yelled, Don't yell at me to one of 16 sampled residents (Resident 6), and was loud enough that Resident 75, Resident 20, and visiting family members (FAM 1) overheard it. This had the potential to compromise Resident 6's dignity and negatively impact other resident's emotional and psychosocial well-being and create an environment of fear. Findings: Resident 6's admission Record was reviewed and indicated that Resident 6 was admitted to the facility for conditions including dementia (a disease that causes memory and thought processes to deteriorate). Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated January, 2023 indicated, It is the practice of [the facility] to protect and promote resident rights and treat each resident with respect and dignity . The policy further stated, 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights; and, 10. Speak respectfully to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-07 · 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 interview and record review, the facility failed to ensure federal regulations related to the education qualification requirements of the Certified Dietary Manager (CDM), were followed as outlined in the California Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with meal distribution accuracy, safe food handling and sanitation guidelines. Findings: According to the HSC 1265.4 a CDM, (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. On 3/5/24 at 8:34 AM, an interview was conducted with the CDM. The CDM stated that…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-07 · tag F0813 — isolated
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure that their, Food from Outside Sources policy (outside sources are food from any other source than the facility's kitchen), included procedures on how to heat or reheat resident food that had been brought in from the outside or contained education for staff and visitors on safe food handling practices and potentially hazardous foods, (PHF-food that allows for rapid progression and growth of bacteria; such as food that consists in whole or part of milk, milk products, eggs, meat, poultry, rice, fish shellfish, edible crustaceans, raw-seed sprouts, and vegetables including heat-treated vegetables). This failure had the potential for residents who received food from a source to be subjected to contaminated food and food borne illnesses such as stomach cramps, nausea, vomiting, diarrhea and food poisoning. Findings: Review of the facility's policy titled, Food from Outside Sources reviewed 1/22, indicated patients are encouraged to consume facility meals, snacks and supplements to assure adequate nutrition and reduce the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-02-17 · tag F0801 — widespread
    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, interview and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when: 1. The Registered Dietitian (RD) did not work full time in the Food and Nutrition Services kitchen, and the Dietary Manager (DM) did not meet qualifications for a director of food and nutrition services. 2. There was not an effective system in place to ensure effective staff training and competency in critical elements of food safety, and staff work practice deficiencies were not identified or corrected by the Registered Dietitian providing oversight to the kitchen, or by the Dietary Manager. These failures had the potential to result in foodborne illness and a decline in medical status for all residents living in the facility. Findings: Review of a policy titled, Organizational Structure/Relationships with Other Departments, revised 10/16, reviewed 1/22, indicated, The Registered Dietitian (RD) is responsible for oversight of Food & Nutrition Service. The Registered Dietitian is qualified by training, licensure 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-02-17 · 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 staff followed professional standards of practice for food safety and sanitation when: 1. Kitchen equipment was not clean. 2. Staff did not utilize proper hand hygiene and glove use to prevent cross food contamination. 3. Potentially hazardous foods were not cooled according to professional standards of practice for food safety. 4. Staff did not ensure that vegetables were properly prepared with food wash according to the manufacturer's recommendations. 5. Stored food was not labeled and dated, and one severely dented can was retained on the can rack with other cans intended for use. These failed practice had the potential of leading to foodborne illnesses for all residents eating food prepared at the facility. Findings: 1. During observations between 2/14/23 at 9:57 am and 2/17/23 at 12:00 pm, multiple pieces of equipment in the kitchen were not clean, including the blender, Robo Coupe (food processor), bulk food bins, can opener, ovens, and walls. During an observation on 2/14/23 at 11:02 am, two bulk…

    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 · Fcited before2023-02-17 · tag F0813 — widespread
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to facilitate and safely store food from outside sources for residents when: 1. Residents were not allowed to store perishable food, and there was not an effective system in place to educate residents and family regarding food brought in from the outside. They were unaware perishable food could be safely stored in a refrigerator. 2. There was not an effective system in place to consistently educate and train nursing staff regarding storage, provision, and reheating of food brought in for residents. These failures had the potential to result in foodborne illness, decreased food intakes, weight loss, decreased medical status and quality of life for all residents living in the facility. Findings: 1. During an observation on 2/15/23 at 11:49 am, Resident 129 was gone to dialysis but had snacks at her bedside. During an observation on 2/16/23 at 8:15 am, Resident 129 refused breakfast. A concurrent review of her breakfast tray ticket showed she was on a Renal, Consistent Carbohydrate diet with regular texture. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-17 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 competent nursing staff for 16 of 16 residents sampled when: 1. The facility staff did not understand the different types of resident abuse and the abuse policy process which would include 16 of 16 sampled residents. This failure to ensure competent staff for facility's abuse process did result in alleged abuse not being reported to California Department of Public Health (CDPH). 2. Two licensed nurses (LNs) did not administer three separate inhalers correctly for Resident 133 and Resident 18, per professional standards of practice for two of sixteen sampled residents. This failure for licensed nurses to omit education, demonstration, verbal cues had the potential for Resident 13 and Resident 18 to not receive therapeutic effect of medications ordered. 3. Three of three nurses did not check therapeutic diet orders for 16 of 16 sampled residents before the Certified Nursing Assistants (CNAs) passed the meal trays. This failure to…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-17 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure its staff were trained and competent to perform their duties according to professional standards of practice when: 1. The food cooling process was not completed consistently or correctly. 2. Produce wash was not tested or used according to manufacturer's instructions. 3. Equipment was not cleaned according to professional standards of practice. 4. Gloves were not changed between tasks to prevent cross contamination. 5. Foods were not consistently labeled and dated. 6. Recipes were not followed. These failures had the potential to result in foodborne illness and decreased meal intakes for all residents receiving meals from the facility. Findings: 1. The food cooling process for Time Temperature Control for Food Safety (TCS) foods was not completed consistently or correctly according to professional standards of practice or facility policy (Cross Reference F812, F801). During an observation in the walk-in refrigerator on 2/14/23 at 10:38 am, cooked pork dated 2/12/23 and cooked pasta dated 2/13/23 were on…

    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 · E2023-02-17 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and document review, the facility failed to ensure meals met resident preferences as evidenced by complaints of cold food, palatability and food quality for 10 residents. (Residents 229, 230, 10, 21, 231, 9, 129, 18, 133 and 134) This failure had the potential to result in decreased meal intake, weight loss, resulting in compromised nutritional status. Findings: During an interview on 2/14/23 at 11 am, Resident 229 stated, she must eat what they brought her even if she didn't care for it. The food was usually cold, and tasteless. During an interview on 2/14/23 at 3:32 pm, Resident 230 stated, the food was not good and that substitutes were not offered. She stated she didn't know she could. Further stated, she just took what she got and it was usually cold. During an interview on 2/15/23 at 10:02 am, Resident 10 stated, the food was cold a lot . several times a week. During an interview on 2/15/23 at 10:15 am, Resident 21 stated, she have been to the facility since 12/17/22, and not being offered alternatives. She stated the grilled cheese was not…

    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 before2023-02-17 · tag F0806 — failed to honor food preferences — pattern
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 accommodate resident food allergies, preferences, and provide appealing alternate food options when: 1. An effective system was not in place to avoid resident's known food allergies, and the facility failed to check one of six sampled residents' diet orders and meal trays for accuracy and safety before delivering the meal tray, (Resident 10). 2. Two residents (Residents 128, 134) reported their food preferences were not honored. 3. Seven residents (Residents 18, 231, 229, 230, 21, 7, 14) reported a lack of choice or ability to access a selection of alternative meals. These failures resulted in Resident 10's allergic reaction to a known food allergy that required medication, and they had the potential to result in decreased nutrition intake, weight loss, decreased quality of life, and decline in medical status for all residents living in the facility. Findings: Review of a policy titled, Serving a Meal, revised 1/23, showed the purpose is to…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two out of six sampled residents, (Resident 10 and Resident 21) was free from abuse and neglect when: a Certified Nursing Assistant (CNA) F was verbally rude, disrespectful, and did not provide care when requested. This failure caused Resident 10 and Resident 21 increased anxiety, loss of dignity, and humiliation. Findings: 1. During a review of a policy revised 1/2023, titled, Abuse Prevention And Management: Transitional Care Unit, (TCU), indicated The purpose of this policy is to define the policies and procedures that have been developed to prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property, manage situations, and conduct investigations when there is an allegation or a finding of abuse. The facility recognizes and supports the laws, rules, and regulations that require all employees to report incidents of mistreatment, neglect or abuse, injuries of unknown source and misappropriation…

    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 · D2023-02-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the facility staff recognized and reported allegations of abuse/neglect for two of six sampled residents (Residents 10 and Resident 21). This failure put all residents at risk for abuse/neglect and injuries which had the potential to result in negative clinical outcomes by not removing the alleged employee from the schedule immediately, and not reporting the alleged abuse within 24 hours. Findings: 1. During a review of a policy revised 1/2023, titled, Abuse Prevention And Management: Transitional Care Unit, (TCU), indicated The purpose of this policy is to define the policies and procedures that have been developed to prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property, manage situations, and conduct investigations when there is an allegation or a finding of abuse. Any employee that observes, or receives a report of abuse, or sees signs of abuse is legally required to report the alleged or suspected…

    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 · Dcited before2023-02-17 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure allegations of abuse/neglect and were thoroughly investigated, staff was trained to take corrective actions to prevent further abuse for two of six sampled residents (Residents 10 and Resident 21). These failures had the potential for ongoing alleged verbal and physical abuse which could lead to many negative outcomes. Findings: During a review of a policy revised 1/2023, titled, Abuse Prevention And Management: Transitional Care Unit, (TCU), indicated The purpose of this policy is to define the policies and procedures that have been developed to prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property, manage situations, and conduct investigations when there is an allegation or a finding of abuse. The facility recognizes and supports the laws, rules, and regulations that require all employees to report incidents of mistreatment, neglect or abuse, injuries of unknown source and misappropriation 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.

    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

No federal fines in the current CMS record.

Part of a chain

This home belongs to VIBRA HEALTHCARE — 3 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 54.0+1.0 vs chain
Health inspection 4 of 53.3+0.7 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 2 homes this chain runs (chain average 4.0★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
HOLLINGER HOLDING COMPANY LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/28/2015
VIBRA HEALTHCARE, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/30/2005
CARR, FRANCISIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2009
DIEBOLD, JAMESIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2009
HOLLINGER, BRADIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 06/24/2005
CREDIT SUISSE AGOrganization5% OR GREATER SECURITY INTERESTsince 07/22/2020
MIDCAP FUNDING IV TRUSTOrganization5% OR GREATER SECURITY INTERESTsince 01/28/2015
VIBRA RE REDDING LLCOrganization5% OR GREATER SECURITY INTERESTsince 06/04/2018
CENIZA-SAELEE, SHEBAIndividualW-2 MANAGING EMPLOYEEsince 06/02/2014
DEFILLIPO, EMILYIndividualW-2 MANAGING EMPLOYEEsince 05/18/2020
STEVENS, LISAIndividualW-2 MANAGING EMPLOYEEsince 10/20/2008
FEGAN, CLINTIndividualCORPORATE OFFICERsince 06/24/2005
HAUCK, DAVIDIndividualCORPORATE OFFICERsince 10/04/2018
HOLLINGER, KELLYIndividualCORPORATE OFFICERsince 03/01/2020
NIEMUTH, TRISHAIndividualCORPORATE OFFICERsince 01/01/2022
VIBRA MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/15/2008

CMS files one row per role, so the 17 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

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 555588. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-23, 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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