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Plymouth Village

819 Salem Drive, Redlands, CA 92373 · Non profit - Corporation · 48 certified beds · (909) 793-1233 Medicare & Medicaid certified

Call the home — (909) 793-1233 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 23 lower-level deficiencies on record (see below)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

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)
  • lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (23) — 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.

4/5
CMS overall
4 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 4 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
700 E Redlands Blvd · (909) 307-6022 · Call to confirm hours
Pharmacy
Rite Aid0.2 mi
700 E Redlands Blvd · (909) 793-3568 · Call to confirm hours
Grocery
450 E Cypress Ave · (909) 792-1114 · Call to confirm hours
Park
1352 Prospect Dr · (909) 798-7655 · 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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 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 improved from 4 to 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 increased5.3%10.2%15.4%better
Long-stay residents who lose too much weight2.1%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 infection3.5%1.2%2.0%worse
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened15.9%9.8%16.1%typical
Long-stay residents on antianxiety or hypnotic medication12.9%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine97.5%98.2%95.3%typical
Long-stay residents with pressure ulcers2.2%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control8.2%10.2%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table2.2%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine97.4%93.2%79.4%better
Short-stay residents rehospitalized after admission24.6%23.0%22.6%typical
Short-stay residents with an outpatient ER visit15.1%11.2%12.0%worse

* 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.

51.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.4%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
83.3%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 83.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 24 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNF51.4%CMS range 36.6–63.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 6.1–15.110.7%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 discharge83.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge83.3%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 discharge75.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 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 hospitalization7.7%CMS range 3.9–13.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.391.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.32
RN hours/ resident / day
1.47
LPN hours/ resident / day
2.74
Aide hours/ resident / day
4.53
Total nurse hours/ resident / day
0.20
RN hoursweekends
26.5%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 48 beds and averages 43.0 residents a day — about 90% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.74 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 4.02 hrs/resident/day on weekends vs 4.74 on weekdays — 15% thinner on weekends. RN hours go from 0.37 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 26% is below the national median of 45%.

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

Inspection trend

6
deficiencies at the latest standard inspection (2025-06-19)
7
at the previous standard inspection (2024-04-26)

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Dcited before2026-05-28 · 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 the clinical record contained accurate documentation of fall history for one of three residents (Resident 1) reviewed for falls.This failure had the potential to result in an inaccurate assessment of fall risk and inappropriate fall prevention interventions, placing Resident 1 at increased risk for subsequent falls.During a review of Resident 1's clinical record, the admission Record (contains demographic and clinical data), the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included unspecified dementia (memory loss beyond expected age and difficulty with thinking), history of falling, and unspecified fracture (break of the bone) of the lower end of the left radius (lower forearm) and left ulna (broken left wrist).During a review of Resident 1's Change in Condition Note, dated April 4, 2026, the Change in Condition Note indicated Resident 1 sustained a fall on April 4,…

    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 · Fcited before2025-06-19 · 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, sanitary food preparation, and storage practices in the kitchen when: 1. The main kitchen floors had accumulation of food crumbs, black stains, and dirt; the walk-in freezer had food crumbs on the floor, and the walk-in refrigerator floors had multiple cilantro leaves, cauliflower pieces, and multiple moist black and brown residue under the shelf. 2. Food equipment such as the toaster had black grime, white residue, and food crumbs; the mixer was found with multiple reddish-orange splashes on the handle. 3. The edge of the wall under the three-compartment sink had black build up and multiple white residues. These failures had the potential to cause foodborne illnesses (caused by the ingestion of contaminated food or beverages) in a highly susceptible population of 44 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on June 16, 2025, at 07:48 AM, with the Sous Chef (SC) in the main kitchen, the floors had an accumulation of food crumbs, black…

    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 before2025-06-19 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained when a Laundry Staff used a dirty laundry basket (a basket for holding clothes and linen that have been washed) to transfer washed linens into the dryer machine. This failure had the potential to cause harm to the 44 residents residing within the facility by increasing the risk of exposure and spread of infection (the process by which an infectious agent (like a virus or bacteria) moves from one source to another, causing illness). Findings: During a concurrent observation and interview on June 18, 2025, at 12:10 PM, in the laundry room with the Infection Preventionist (IP), Laundry Supervisor (LS) and Laundry Staff (LS 1) observed a large rectangular blue plastic laundry basket with a lid covered with stained dirty white sheet located near the dryer. LS 1 stated the laundry basket is used to transfer washed linens from the washing machine to the dryer. The LS stated the white sheet on top of the laundry basket are changed every day. LS1 stated the white…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of seven residents (Residents 4) reviewed for dining observation when a Licensed Vocational Nurse (LVN 2) was standing over Resident 4 while feeding him lunch on June 16, 2025. This failure resulted in staff not maintaining Resident 4's individuality and dignity. Findings: During a review of Resident 4's admission Record (contains demographic and medical information), undated, the admission Record indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses of Hemiplegia, unspecified affecting right dominant side (weakness on one side of the body), Dysphasia (condition affecting speech) and dysphagia (difficulty swallowing). During an observation on June 16, 2025, at 12:24 PM, in the second dining room, LVN 2 was standing over Resident 4 while feeding him lunch. During an interview on June 16, 2025, at 1:00 PM, LVN 2 stated staff are expected to be seated while feeding residents.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe oxygen administration were provided in accordance with the physician's orders and facility policies and procedures for one of three sampled residents (Resident 12) reviewed for respiratory care when Resident 12's oxygen tubing (a device which delivers oxygen) was not labeled to indicate the date that it was changed. This failure had the potential for Resident 12 to be at risk of developing a respiratory infection (caused by bacteria, viruses, fungi, or parasite). Findings: During a review of Resident 12's clinical record, the admission Record (patient demographics), indicated, Resident 12 was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that makes it hard to breathe), diastolic (congestive) heart failure (a condition where the heart muscle is too stiff to relax properly, preventing the heart from filling with enough blood between beats), and atrial fibrillation…

    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 · D2025-06-19 · 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, the facility failed to ensure medication error rate was less than five percent. There were two medication errors identified out of 27 opportunities for errors, affecting one of 13 residents (Resident 14), resulting in an overall medication error rate of 7.4 percent when Resident 14's Levothyroxine (replacement hormone for people whose thyroid gland is not working properly) and Hydrocodone-Acetaminophen (medication used to relieve severe pain) were crushed together during medication administration. These failures had the potential for Resident 14 to have negative health consequences and effectiveness of the medications. Findings: During a review of Resident 14's clinical records, the admission Record (contains demographic and medical information) indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included, gastro esophageal reflux (a condition where stomach acid flows back up into the esophagus), hypothyroidism (a condition when…

    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 before2025-06-19 · 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 the privacy of patient health records for one of six sampled residents (Resident 14) was maintained when a Licensed Vocation Nurse (LVN 3) left Resident 14's health information on the computer screen, unattended in the hallway, visible for anyone to see. This failure had the potential for Resident 14's private information to be disclosed without authorization which could lead to Health Insurance Portability and Accountability Act (to protect medical records and other personal information) violations. Findings: During a review of Resident 14's clinical records, the admission Record (contains demographic and medical information) indicated, Resident 14 was admitted to the facility on [DATE], with diagnoses which included, gastro esophageal reflux (a condition where stomach acid flows back up into the esophagus), hypothyroidism (a condition when the thyroid gland doesn't make enough thyroid hormone) and pain in thoracic spine (middle…

    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 · F2024-04-26 · tag F0726 — failed to have competent, trained nursing staff — widespread
    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

    Based on interview and record review, the facility failed to implement a process to routinely evaluate contracted nursing staff on their skill levels (range of tasks and duties to be performed) and develop individualized competency-based training (a process to acquire skills and knowledge to be able to perform a task to a specified standard) for 10 of 10 contracted staff (one Licensed Vocational Nurse [LVN 1], and nine Certified Nursing Assistants [CNA 1, 2, 3, 4, 5, 6, 7, 8 and 9]). This failure had the potential to compromise the services and types of care necessary to safely meet the resident's needs. Findings: During an interview and record review on April 25, 2024, at 2:30 PM, with the Director of Nursing (DON), the DON reviewed the document titled, Orientation Checklist dated March 20, 2020, the checklist indicated, Skills-C.N.A . Ambulation . Bed making .Body Mechanics . Position in Bed .Charting and Reporting .Bladder Training . Foley Catheter Cares . Vital Signs . The DON stated the facility used the checklist for contracted nursing staff. DON was not able to provide…

    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 · F2024-04-26 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    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 record review, the facility failed to store food by methods that conserve nutritive value, flavor, and appearance, when four bags of raw chicken had freezer burn (frozen foods are exposed to cold, dry air, which causes them to dehydrate as the outer layers lose moisture. One of the most commonly recognized signs of freezer burn is the formation of ice crystals on the outside of food, making it appear frost bitten). This had the potential for the chicken to not be palatable when cooked and served to 40 of 41 medically compromised residents who received food from the kitchen. Findings: During an observation on April 22, 2024 at 9:00 a.m., inside the walk-in freezer, there were four bags of frozen chicken that had ice build-up and the bags had a lot of air that was keeping the bags expanded. During an interview with the Food Service Director on April 24, 2024, at 12:03 p.m., She stated that no food in the freezer should have any ice build-up or freezer burn. During a review of the facility policy titled Production, Purchasing, Storage, dated January…

    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 before2024-04-26 · 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 maintain a sanitary kitchen when: 1. Floors under equipment in multiple areas of the kitchen had a build up of black grime, old food, crumbs, and trash, this had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted. 2. Two convection (fans to circulate air around food to create an evenly heated environment) ovens, two ranges, a grill top, a food warmer box (appliance that holds already cooked foods at ideal temperatures until they are ready to be served) and 4 waffle irons, had a buildup of black grime, and yellow crusted grime. This had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted. 3. Two buckets used as funnels to drain cooking liquid from a large steam kettle (used to cook large quantities of liquid-based foods) were crusted with old food. This had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted. These…

    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 13 citations
  • Potential for harm · D2024-04-26 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 appropriate treatment and management of a gastrostomy tube (G-tube, a tube inserted through abdomen that delivers enteral feeding formula and hydration directly to the stomach) was implemented for one of two sampled residents with G-tube (Resident 37), when: 1) The G-tube pump (a machine which helps to deliver the enteral formula to the resident), was off and 1500 cc (cc - unit of volume) of Glucerna (enteral feeding formula) 1.2 cal [calories] was left in the bottle. This failure resulted in Resident 37 not receiving the calculated amount of enteral feeding formula for the day, as per physician's orders. 2) The order for Glucerna 1.2 cal was not transcribed (written) accurately onto the physician's orders (It was ordered via oral route of administration on April 1, 2024, instead of via G-tube). This failure has the potential for Resident 37 to receive the enteral feeding formula via the wrong administration route. Findings: 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 · Dcited before2024-04-26 · 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 maintain accurate records of controlled medications (narcotic medications that are controlled by the government because it may be abused or cause addiction) for one of two medication carts (Front Hall medication cart), with seven missing signatures for narcotics count. This failure had the potential for drug diversion (Illegal distribution of controlled drugs for any illicit use) of controlled medications by the staff. Findings: During concurrent interview and record review on April 24, 2024, at 6:30 AM, with the Director of Nursing (DON), the DON reviewed the Front Hall medication cart's narcotics shift count verification signature log (a form used by facility to verify counting of controlled drugs at the change of shift by oncoming and off going licensed nurses), dated March 2024 and April 2024. The log indicated the following: a. On March 20, 2024, missing signatures on the night shift (NOC) from Signature 1 (incoming nurse) and Signature 2 (outgoing nurse). b. On March 26, 2024, missing signature on NOC…

    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 · D2024-04-26 · 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 drugs and biologicals were labeled in accordance with currently accepted professional principles for one of one resident (Resident 247) when a bubble pack (a card that packages doses of medications within plastic bubbles organized by day and time of the day) containing morphine (medication used to treat pain) had no expiration date ( a date that indicates when medicine is no longer effective) written in the label. This failure had the potential to result in staff administering an expired medication to Resident 247 which can alter the efficacy (ability to produce desired effects) of the medications and reduce its therapeutic effectiveness. Findings: During a concurrent observation and interview on [DATE], at 6:15 AM, with the Director of Nursing (DON), the medication storage Cart 1 located at the front hallway, was inspected. A bubble pack containing Resident 247's Rx# (prescription number) 159536, Morphine Sulfate (MS), 15…

    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 before2024-04-26 · 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 a sanitary and safe medication storage in one of two medication carts (a cart used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment) when the hearing aids (a small device that fits in or on the ear, worn by a partially deaf person to amplify sound) for four of four residents (Resident 39, 29, 13 and 25) were found inside a medication cart's narcotic drawer. This failure had the potential for cross contamination and infection (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and jeopardize the health and safety of (Resident 39, 29, 13 and 25). Findings: During a concurrent observation and interview on April 24, 2024, at 5:40 AM, with the Director of Nursing (DON), the DON reviewed the Front Hall medication cart. The DON opened the narcotic drawer inside the medication cart. The narcotic drawer contained two small black cases, one small gray…

    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 · Fcited before2023-03-10 · 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 maintain a sanitary kitchen environment when: 1) The two ice machines that provide ice for 37 of 38 residents of the facility, were not clean to sight and touch. Ice machine 1 had a yellowish build-up in the ice chute (where ice is dispensed and travels from the ice maker to enter the ice bin). Ice machine 2 had a brownish build-up. This had the potential to contaminate the ice and cause foodborne illness. 2) The walk-in freezer that provides storage of food for 37 of 38 residents had liquid food spills, food crumbs and trash on the floor. This had the potential for microorganism growth and to attract pests. 3) The cabinet below the steam table (appliance that keeps food warm after it's been prepared and cooked) in the dining room that services meals for 37 of 38 residents had food crumbs and a rusty liquid spill. This had the potential for microorganism growth and to attract pests. Findings: 1. During an observation of Ice Machine 1, on March 7, 2023, at 9:00 AM, in the beverage area of the dining room, 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 · D2023-03-10 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 17) was provided reasonable accommodation of needs, when Resident 17's hearing deficit was not addressed by the facility. This failure resulted in Resident 17 not receiving an adequate hearing assessment and Resident 17 potentially failing to achieve her highest level of functioning, dignity, and well-being. Findings: During a concurrent observation and interview on March 7, 2023, at 8:02 AM, with Resident 17, in Resident 17's room, Resident 17 was observed to be hard of hearing. Resident 17 asked surveyor to repeat what was said because she could not hear. Surveyor repeated what was said multiple times, and spoke louder, slower, and closer to Resident 17's ear. Resident 17 stated she would have to talk to her son about getting hearing aids. During an interview on March 8, 2023, at 9:48 AM, in Resident 17's room, with Registered Nurse 1(RN 1), RN 1 stated Resident 17 had difficulty hearing…

    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 · D2023-03-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 28) was provided a safe, clean, comfortable, and homelike environment when Resident 28's wheelchair was not found in good repair. This failure had the potential to result in discomfort for Resident 28, which could have negatively impacted the resident's quality of life. Findings: During a concurrent observation and interview on March 7, 2023, at 10:40 AM, with Resident 28, in Resident 28's room, the vinyl fabric (a durable, waterproof, man-made synthetic leather) lining of Resident 28's wheelchair was observed to be torn on both sides of the backrest, where it connected to the wheelchair frame. The exposed fabric was partially covered with dirty, peeling, paper medical tape. Resident 28 stated, the wheelchair was provided to him by the facility and had been torn since he was admitted in October 2021. During a concurrent observation and interview on March 10, 2023, at 9:51 AM, with the Infection Preventionist (IP), in the IP's office, Resident 28's wheelchair was…

    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 · D2023-03-10 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 accurately assess a resident with a hearing deficit when one of three sampled residents (Resident 17), Minimum Data Set (MDS -a federally mandated assessment for residents in nursing homes) who was known by the staff to have a hearing deficit. This failure had the potential to cause Resident 17 to receive inadequate care at the facility and adversely affect Resident 17's quality of life and ability to function since the time of admission. Findings: During a concurrent observation and interview on March 7, 2023, at 8:02 AM, with Resident 17, in Resident 17's room, Resident 17 was observed to be hard of hearing. Resident 17 requested surveyor to repeat what was said because she could not hear. Surveyor repeated what was said multiple times, while spoken louder, slower, and closer to Resident 17's ear. Resident 17 stated she would have to talk to her son about getting hearing aids. During an observation on March 7, 2023, at 9:48 AM, in…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-10 · 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 interview and record review, the facility failed to develop and implement a comprehensive care plan for two of four sampled residents (Resident 9 and Resident 28) receiving anticoagulant (blood thinner) medication. This failure had the potential to cause adverse health outcomes such as bleeding and hemorrhage (profuse discharge of blood from a ruptured blood vessel) which may lead to hospitalization and/or death. Findings: 1. During an interview on March 7, 2023, at 11:16 AM, with Resident 9's responsible party (RP), RP stated Resident 9 is taking Xarelto (anticoagulant medication to prevent blood clots), and Resident 9 would get bruises whenever her blood is drawn for laboratory work. RP further stated after Resident 9's recent stroke, communication became harder because Resident 9 did not talk as much. During a review of Resident 9's medical record, the Face Sheet, (contains admission and demographic information) dated March 10, 2023, the Face Sheet indicated Resident 9 was admitted on [DATE], with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-10 · 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 professional standards of practice for urinary catheter (flexible tube used to empty the bladder and collect urine in a drainage bag) care for one of three sampled residents (Resident 28), when Resident 28 was instructed to hold his catheter during a urinary catheter irrigation (a sterile procedure to flush the urinary catheter to keep it clear and working properly) procedure. This failure had the potential to result in a urinary tract infection (UTI - an infection in any part of the urinary system) due to improper handling of the urinary catheter, which could have caused the resident harm. Findings: During a review of the Face Sheet (contains admission and demographic information) for Resident 28, dated March 10, 2023, the Face Sheet indicated, Resident 28 was admitted on [DATE], with a diagnosis of, but not limited to, benign prostatic hypertrophy (BPH-a condition causing slowing or blockage of the urine stream out 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-10 · 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 the accurate administration of prescribed drugs and biologicals, when a medication was not administered as ordered by the physician for one of seven sampled residents (Resident 17). This failure resulted in Resident 17 receiving a doubled dosage of an ordered laxative medication which resulted in a medication error and had the potential to cause adverse drug effects to the resident. Findings: During a review of the Face Sheet (contains admission and demographic information) for Resident 17, the Face Sheet indicated, Resident 17 was admitted on [DATE], with a diagnosis of Alzheimer's disease (the most common cause of dementia - an impaired ability to think, remember, or make decisions), encounter for palliative care (specialized medical care for people living with a serious illness), bed confinement, and pressure ulcer of sacral region- stage 4 (full thickness damage to the skin and underlying soft tissue of the lower back, just…

    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 before2023-03-10 · 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 observe infection prevention and control measures for two of two sampled residents (residents 28 and 30) when: 1. Resident 28's wheelchair was ripped. 2. Resident 30's toothbrush and hair comb were found in a shared bathroom sink, unlabeled. These failed practices had the potential for the spread of infection and placing residents' health and safety at risk of a highly susceptible population of 39 residents. Findings: 1. During a concurrent observation and interview on March 7, 2023, at 10:40 AM, with Resident 28, in Resident 28's room, the vinyl fabric (a durable, waterproof, man-made synthetic leather) lining of Resident 28's wheelchair was observed to be torn on both sides of the backrest where it connected to the wheelchair frame. The exposed fabric was partially covered with dirty, peeling, paper medical tape. Resident 28 stated the wheelchair was provided to him by the facility and had been torn since he was admitted in October…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-10 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a safe environment for all residents in the facility, when an open gap on the dining room floor was present. This failure had the potential to impose a tripping hazard for the residents and could have contributed to resident falls with injuries. Findings: During an observation on March 7, 2023, at 11:00 AM, an open gap in the flooring of the dining room floor was observed, measuring approximately six inches long and one inch wide. An interview on March 7, 2023, at 11:00 AM, with the Administrator, the Administrator stated, he didn't know why the gap in the flooring was there. The Administrator stated, he will get it fixed immediately. During an interview on March 8, 2023, at 12:08 PM, with Maintenance, Maintenance stated, he didn't know how long the open gap had been there. Maintenance stated the gap in the floor may have been there for a few months, due to the build-up of dirt around it. During an interview on March 9, 2023, at 10:53 AM, with the Administrator, the Administrator stated, housekeeping…

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

    Environmental Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to HUMANGOOD — 17 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 54.5-0.5 vs chain
Health inspection 4 of 53.6+0.4 vs chain
Staffing 4 of 54.9-0.9 vs chain
Quality measures 4 of 54.2-0.2 vs chain
The other 16 homes this chain runs (chain average 4.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
HUMANGOOD NORCALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 01/01/1967
HUMANGOODOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 05/01/2016
U.S. BANKOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 04/01/2018
BAKER, JUDITHIndividualCORPORATE DIRECTORsince 04/25/2012
BATTISON, WILLIAMIndividualCORPORATE DIRECTORsince 05/01/2016
BROWN, HERMANIndividualCORPORATE DIRECTORsince 05/01/2016
CHRISTOPHERSON, JOANNEIndividualCORPORATE DIRECTORsince 03/20/2025
FELLER, IRENEIndividualCORPORATE DIRECTORsince 01/26/2021
GRIFFITH, ALANIndividualCORPORATE DIRECTORsince 06/30/2019
HOLMES, MICHELLEIndividualCORPORATE DIRECTORsince 05/01/2016
KELLEY, ALBERTIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/01/2016
ROTH, SHARONIndividualCORPORATE DIRECTORsince 12/08/2018
VANGELISTO, GWENIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/30/2021
COCHRANE, JOHNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/10/2009
GHASSEMI, BETHANYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 05/21/2019
MCDONALD, ANDREWIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
OGUS, DANIELIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 08/27/2009
HUMANGOOD SOCALOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/1967
DAVIS, VICTORIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/06/2023
DRAKE, BRETTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/14/2024
HARRISON, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/02/2024
LOPEZ, JESSICAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/20/2020
NASSAR, MOHAMEDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2020
BAKER TILLY US LLPOrganizationADP OF THE SNFsince 10/15/2024
HANSENOrganizationADP OF THE SNFsince 03/27/2017
WASHINGTON FEDERALOrganizationADP OF THE SNFsince 10/27/2020

CMS files one row per role, so the 44 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$20.8M
Net patient revenuemost recent cost report
+1.2%
Operating marginrevenue minus expenses
$1.2M
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 6%Medicare 1%Other / private 94%

This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$200per resident / day
operating cost
$6,078per month
≈ monthly operating cost
$202per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055914. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-19, 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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