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Devonshire Oaks Nursing Center

3635 Jefferson Avenue, Redwood City, CA 94062 · For profit - Corporation · 38 certified beds · (650) 366-9503 Medicare & Medicaid certified

Call the home — (650) 366-9503 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

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)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2950 Whipple Ave · (650) 364-2864 · Call to confirm hours
Pharmacy
2450 Park Rd · (650) 362-4192 · Call to confirm hours
Grocery
3115 Jefferson Ave · (650) 520-8380 · Call to confirm hours
Park
3600 Glenwood Ave · (650) 780-7311 · Typically dawn to dusk
Place of worship
3623 Jefferson Ave

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.4%10.2%15.4%better
Long-stay residents who lose too much weight15.1%4.0%5.4%worse
Long-stay residents with a catheter left in their bladder2.4%0.8%0.9%worse
Long-stay residents with a urinary tract infection2.2%1.2%2.0%worse
Long-stay residents with depressive symptoms1.4%7.3%6.5%better
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 worsened10.1%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication7.0%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine85.7%98.2%95.3%worse
Long-stay residents with pressure ulcers2.3%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control10.4%10.2%21.2%typical for the state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table16.3%12.0%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine79.1%93.2%79.4%typical

* 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.

60.2% 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 61 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.2%U.S. median 51.5%
Got home and stayed home
12.3%U.S. median 10.7%
Went back to hospital
56.4%U.S. median 56.6%
Met the expected recovery
0.52U.S. median 0.31
Therapy hours / resident / day
0.35hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 56.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 39 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 0.52 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 SNF60.2%CMS range 48.6–71.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.3%CMS range 6.9–18.110.7%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 discharge56.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge48.7%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 discharge48.7%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 identified91.1%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 setting97.2%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 stay3.6%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 hospitalization5.8%CMS range 2.6–10.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 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

1.37
RN hours/ resident / day
0.67
LPN hours/ resident / day
2.60
Aide hours/ resident / day
4.64
Total nurse hours/ resident / day
0.69
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 38 beds and averages 31.7 residents a day — about 83% 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 4.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.37 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 3.91 hrs/resident/day on weekends vs 4.94 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.65 to 0.69 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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 (2025-01-17)
14
at the previous standard inspection (2023-10-27)

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.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2023-08-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent a fall for one of one sampled resident (Resident 1) when the Certified Nurse Assistant (CNA, caregiver) left Resident 1 on right side lying position in bed and without supervision. The facility failure resulted to Resident 1 falling out of bed and sustained a skin tear over a bump above the left eyebrow/forehead, bruising of the left eye, left side of the face, to the left side of the neck and the left upper chest). Findings: A review of the face sheet indicated Resident 1 was admitted with diagnoses including cerebrovascular accident (stroke), epilepsy and tachycardia (abnormally rapid heartbeat). A review of the quarterly Minimum Data Set (MDS, a standard Assessment tool) dated 1/2/23 Brief interview of mental status (BIMS, a brief memory test to help determine cognitive function) indicated severe cognitive impairment. Resident 1 has no speech. Under functional status, Resident 1 required extensive assistance of two persons…

    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 · Fcited before2025-01-17 · 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 interview and record review, the facility failed to 1. offer snacks to every resident who did not have contraindications. Total residents' census on 1/13/2025 was 29 residents. 2. Unpasteurized eggs were provided to residents who wanted fried eggs for breakfast on 1/14/2025. 3. The temperature of the water at the handwashing sink in the kitchen did not reach a level warm enough for washing hands. This failure resulted in possible contaminated food to residents, residents who did not receive a snack, and insufficient warm water for kitchen staff to wash their hands with. Findings: 1.) During an interview on 1/15/2025, at 10:20 a.m., the Dietary Manager stated, Residents have to ask for snacks because a lot of it gets thrown away and wasted . Residents who can't ask for snacks need a recommendation by the dietician, nurse or doctor. Review of Nourishment Policy, dated 2023, indicated, Policy: Nourishments or between meal snacks shall be provided when required by the diet prescription. Bedtime snacks of a nourishing quality will be offered routinely to all residents unless…

    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 before2025-01-17 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for two of two new admissions: Residents 18 and 36. This failure had the potential to negatively affect continuity of care and communication for nursing staff, decreasing resident safety, and an inability to monitor the resident's progress based on their changing needs and preferences. Findings: During a concurrent interview and record review on 1/14/25 at 3:55 p.m., with the Minimum Data Set (MDS- a standardized assessment tool used to comprehensively evaluate the health status of each resident) Coordinator, the facility's policy and procedure (P&P) titled, Preliminary Care Plans, dated August 2006 was reviewed. The P&P indicated a preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty- four (24) hours of admission . to assure that the resident's immediate care needs are met and maintained. Resident 18 was admitted 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-17 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to complete a comprehensive care plan for one of three sampled resident (Resident 4) when there was no evidence of documentation of a completed comprehensive care plan for foley catheter for Resident 4 This deficient practice had the potential to result in inadequate care and services rendered to Resident 4. Findings: Review of the admission Record, dated 1/15/2025, indicated, Resident 4 was readmitted to the facility on [DATE], original admission date 10/1/2024. Review of the admission History and Physical, dated 12/5/2024 indicated, the diagnoses that included, Hemiplegia and Hemiparesis (both are terms to describe weakness or inability to move muscles on one side of the body) following a cerebrovascular disease (disrupt blood flow to the brain leadin to lack of oxygen and nutrients) affecting left non dominant side, retention of urine, unspecified. During an interview on 1/16/2025 at 11:26 a.m., with Social Services (SS), SS stated, we…

    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 · D2025-01-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and review resident's status after an identified change of condition on one resident (Resident 12), when resident 12 had a change of condition on 1/5/25, no care plan and no interdisciplinary documentation and monitoring of change of status. This failure has potential for resident's needs not being met. Findings: Review of Resident 12' s, admission record, dated 1/16/25, indicated, admitted on [DATE] with diagnoses including: Dementia (progressive decline in cognitive abilities such as memory, thinking, reasoning, and problem-solving) without behavioral disturbance, Other Seizures (uncontrolled movements, behaviors, sensations or states of awareness), Diabetes Mellitus (increased blood sugar requiring medication), Down Syndrome (a genetic disorder that causes distinct facial appearance and developmental delays). Review of facility progress notes, dated 1/5/25 at 11:58 p.m., indicated, around 6:48 p.m., the resident has an episode…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-17 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure controlled medications (medications that can be easily abused and are under strict government control) without witness signatures for two residents, Resident 1 and Resident 2. This failure had the potential for controlled drug abuse or diversion (when the transfer of any legally prescribed substance from the individual for whom it was prescribed to another person for any illicit use). Findings: During a concurrent interview and record review on [DATE] at 3:31 p.m., with Director of Nursing (DON) in the med room, the Polaris Rx Narcotic (a drug or other substance that affects mood or behavior and is consumed for nonmedical purposes, especially one sold illegally) Destruction Log dated [DATE] was reviewed. The Polaris Rx Narcotic Destruction Log indicated there were no signatures or dates of destruction witnessing the waste (drugs that can no longer be used because of being expired, unused, spilled, withdrawn, recalled, damaged, contaminated, or…

    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 · D2025-01-17 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a coordinated plan of care and communication process with the Hospice agency, when there was no care plan to address what services Hospice will provide and for facility and when to notify Hospice for two of two Hospice residents, (Resident 4 and Resident 28). This failure has the potential to place residents health and well -being at risk of harm. FINDINGS: 1. Review of Resident 28's admission record dated [DATE], indicated admitted to SNF under Hospice Services 10/24 with diagnosis of End Stage of Alzheimer's Dementia (a terminal decline in cognition including memory, problem-solving., thinking, and reasoning). Review of untitled document, indicated, [DATE], admitted to (name of Hospice) Care, alert and verbally responsive, incontinent of bowel and bladder, fell yesterday at home. She is No CPR, comfort care measures only . During an interview on [DATE] at 11:00 a.m., with Resident 28's family member, family member stated she took…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-10-27 · 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 standards of practice when 1) frozen meat was thawed using water with no system for time/temperature control monitoring; 2) use of sanitizer that was not in accordance with manufacturer's recommendations; 3) use of drying cloth on cleaned/sanitized food production equipment and utensils; 4) lack of an air gap in food production related equipment; 5) lack of overall kitchen cleanliness; 6) storage of unlabeled, undated and spoiled foods; and 7) presence of an open rodent bait station. Failure to implement and maintain food safety standards may put the facility census of 30 residents at risk for foodborne illness or contamination of food which may result in decreased intake and weight loss further compromising medical status. Findings: 1. The standard of practice when thawing meats is to ensure time/temperature control for food safety. There are several ways in which meat can be thawed, one of which would be to utilize running water as a method. When using running water, the food product…

    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 · E2023-10-27 · tag F0661 — pattern
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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 provide discharge summaries for two (Resident 24, Resident 25) of three discharged patients reviewed when Residents 24 and 25 did not have discharge summaries in their clinical records. This failure had the potential for residents not to have follow up care in their homes and could lead to a lack of continuity of care in the community. Findings: 1. A review of Resident 25's facility document, admission Record, dated 10/26/23, indicated, Resident 25 was .admitted to facility on 6/8/23 with diagnoses including: Fracture of T11-T12 Vertebra (compression fracture of the bottom part of the thoracic spine), Dizziness (a sense of disorientation or lightheadedness), Osteoarthritis (a type of degenerative joint disease with symptoms of joint pain and stiffness) . discharge date : [DATE]. A review of Resident 25's facility document, Order Summary Report, order date range 6/8/23-9/1/23, indicated, RNA program 3x/week x 3 months (1). Ambulate pt using FWW 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 · Ecited before2023-10-27 · 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 food production observations, dietary staff interview and dietary department document review the facility failed to ensure adequate staffing and staff competency when 1) dietary department staffing did not allow for adequate food production staff which resulted in the Director of Food Services routinely covering food production positions/duties and 2) Dietary Staff 1 was unable to demonstrate proper thermometer use and 3) Dietary Staff 1 did not prepare meals in accordance with standardized recipes. Failure to ensure adequate staff and staff competency may result in meals not prepared in accordance with resident preferences and acceptable standards of practice further compromising medical status. Findings: 1. During initial tour on 10/23/23 beginning at 9:30 AM, Dietary Staff 2 introduced herself as the Director of Food Services. DS 2 also indicated she was covering for the [NAME] as the person who was scheduled to cook was ill. DS 2 indicated for this morning it would be herself and one diet aid responsible for all food production activities for breakfast and lunch. DS 2…

    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 · E2023-10-27 · tag F0803 — failed to meet residents' dietary needs — pattern
    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 meal distribution observations, dietetic staff interview and departmental document review the facility failed to ensure meals were distributed in accordance with resident preferences and physician ordered diets when 1) staff did not follow a vegetarian menu/plan and 2) three residents with physician ordered mechanical soft received the same lettuce as those on regular diets in a feeding census of 29. Failure to ensure residents receive meals in accordance with approved menus may result in compromising nutritional and/or medical status. Findings: During meal distribution observation on 10/23/23 and 10/24/23 beginning at 12:00 PM, it was noted dietary staff were not following the menu written for physician ordered diets. On 10/23/23 there was one resident whose preference was a vegetarian diet. Dietary 3 plated the meal as ½ cup of pasta, 1 slice bread, ½ cup zucchini and 2 slices cheese. Similarly, during the noon meal on 10/24/23 the vegetarian diet's meal plate was limited to ½ cup brown rice, ½ cup beans and ½ cup carrots. It was also noted residents on physician ordered…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Ecited before2023-10-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure hot food was served that is palatable, in proper temperature and appetizing texture, when test tray temperature was not in range per policy. This practice had the potential to negatively impact the resident's dining experience which may result in poor dietary intake potentially compromising health and nutritional status of 30 residents. Definitions: 1. Food palatability - refers to the taste and/or flavor of the food acceptable to the taste. 2. Proper (safe and appetizing) temperature - both appetizing to the resident and minimizing the risk for scalding and burns. Findings: The guidance per the State Operations Manual (SOM) Appendix PP dated 2/3/23, from the Centers for Medicare and Medicaid Services (CMS) indicated, food should be palatable, attractive, and at a safe and appetizing temperature as determined by the type of food to ensure resident's satisfaction. Appendix PP also indicated, providing palatable, attractive 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 · D2023-10-27 · 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 observation, interview, and record review, the facility failed to provide Resident 227, one of 14 sampled residents, with a dignified existence when the resident was the last resident to be fed lunch after all the other residents. This failure has the potential for physical and psychosocial harm by neglecting and delaying meals to resident. Findings: Resident 227 was admitted to facility on 5/10/22 with diagnoses including dementia (impaired memory and judgement which interferes with daily functioning), brain disease, hydrocephalus (buildup of fluid on the brain causing difficulty walking, memory problems, problems with balance and coordination, is incurable), and hypertension. Resident's Minimal Data Set (MDS, an assessment tool), indicated impaired cognition (thinking ability), inability to ambulate (requires reclining wheelchair for mobility), unable to communicate, requires assistance to eat, requires total assistance to reposition in bed or transfer to chair/bed. During a dining observation on 10/23/23 at 12:35 PM, Resident 227 was in the dining room, in the reclining…

    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 · D2023-10-27 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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 treat Resident 16, one of 14 sampled residents, with respect and dignity when the residents room door was found closed, and the resident, who was non-speaking, was observed in bed, wide awake, with one blanket, no sheets, or bed pillow, in a bare, two bed room, with minimal furniture, bare walls, with the residents nurse call light on the other side of the room, no drinking water or water pitcher, a bare over-bed table which was standing in the middle of the room and the bathroom door was blocked, from entering the bathroom, with a medium-sized nightstand. This failure had the potential to depress and isolate the resident resulting in mental distress and causing the resident to feel helpless, excluded and outcast from the facility. Findings: Resident 16 was admitted to the facility on [DATE] with diagnoses including dementia (impaired memory and judgement which interferes with daily functioning), kidney disease, depression (feeling of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-27 · 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

    Based on observation, interview, and record review, the facility failed to accomodate resident needs for Resident 127, one of 14 sampled residents, when the resident, who is bed-bound, had an improperly functioning television since his admission, over ten days ago. This failure had the potential to cause the resident feelings of depression (feeling of sadness and loss of interest), frustration, and resentment. Findings: Resident 127 was admitted to facility on 10/12/23 with diagnoses including cellulitis (serious bacterial skin infection), with draining wounds to both knees, arthritis, diabetes (elevated levels of sugar in the blood), and muscle weakness, due to medically complex conditions. Resident could not walk or stand and was restricted to bed. During an observation on the initial tour, 10/23/23 at 10:30 AM, Resident 127 was lying in bed, not moving, on his back, looking up at the television which he stated only receives one station. He stated he was annoyed that he could not view other stations. He stated he told the facility engineer about the problem before he went 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-27 · 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 provide a safe, clean, comfortable, environment when the women's bathroom, in the main hallway of the facility, was not working properly for four days and there was no maintenance personnel available to maintain equipment. This failure had the potential to cause frustration, impatience, and disappointment for staff, visitors, and residents who utilize and require facility services. Findings: In an observation on 10/23/23, at 10:35 AM, the facility women's bathroom located in the main hallway of the facility did not work properly. During an interview with the Director of Nurses (DON) on 10/23/23, at 11:15 AM, DON stated the facility Engineer went on vacation last Friday, 10/20/23, for one month. The DON stated another Engineer will be coming today. In an observation on 10/24/23, at 10:00 AM, the women's bathroom in the main hallway was not working properly. The Engineer did not arrive yesterday, 10/23/23. During a concurrent interview with the DON, DON stated the Engineer was expected today. In an observation…

    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 before2023-10-27 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to create a baseline care plan based on Admitting orders for one of three residents (Resident 3) reviewed when Resident 3 admitted [DATE] with Diagnosis of Cancer (abnormal cells) of the Breast, had no initial care plan. This failure could result in Resident 3 not getting the follow up care needed for Cancer treatment. Findings: A review of Resident 3's admission Record dated, 10/26/23, indicated, admitted to facility on 9/26/22 with diagnosis of Malignant Neoplasm of Unspecified site of Right Female Breast (Cancer of the Breast). A review of Nutrition/Dietary Note, Initial Assessment 9/27/22, indicated, admitted with Cancer of the Breast. On 12/2/22 , weight trending down since admit. On 9/29/23, RD indicated, weight loss continues. No care plan by RD to include Cancer of the Breast. A review of the facility Care Plan, initiated 10/2/22, no care plan found to address Diagnosis of Breast Cancer and its treatment plan and follow up visits. A review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-27 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to revise the fall care plan for one of three sampled residents (Resident 9) after her fall incident on 7/29/23 and 8/3/23. This failure had the potential not to prevent from another fall. Findings: Review of Resident 9's clinical record indicated, Resident 9 was admitted to the facility with diagnoses including dementia (memory loss), anxiety disorder (a mental health illness characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), restlessness and agitation (extreme motor activity or inner restlessness). Review of Resident 9's clinical record titled, SBAR (Situation, Background, Assessment, Recommendation) and Progress Note for COC (Change of Condition) dated 7/29/23 indicated, . unwitnessed fall . 07/29/2023 . At around 1930 (7:30 p.m.), resident found on the floor . unable to determined what happened. Denies pain, no skin discoloration noted . no change in LOC (Level of Consciousness, a resident's level of arousal and awareness) . Resident able to ambulate…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-27 · tag F0732 — isolated
    Post nurse staffing information every day.
    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 post the daily Staffing Assignment Schedule, in a prominent place, at the beginning of each shift, in a clear and readable format, accessible to residents and visitors, when the schedule was kept stored in a binder, behind the nurses desk, on a shelf, instead of an easily located place for everyone, etc., to find and read. This failure had the potential for visitors, family, staff, residents, etc., not to find the appropriate assigned staff who should provide needed care to a resident and could lead to inadequate care to residents. Findings: In an observation on 10/23/23 at 10:20 AM, there was no visible posting of the Staffing Assignment Schedule, in a prominent place, at the nurses station near the facility entrance. During a consecutive interview with the Director of Nurses (DON), she stated she would locate the Staffing Assignment Schedule and post it. In a consecutive observation of the DON, she found a binder located behind the nurses station filed on a shelf. She located the Staffing Assignment…

    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 · D2023-10-27 · 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 assure medical supplies were not expired when review of stored medical supplies showed some supplies had an expired date. This failure would have resulted in questionable integrity of the medical supplies and deliver poor quality of care to the residents. Findings: During a review of stored medical supplies on [DATE], at 2:30 PM, accompanied by the Director of Nursing (DON) it was discovered that: One Tuberculin syringe had expired [DATE], 30 packets Veltassa oral suspension (treats high blood potassium) 8.4 gm (gram, a unit of measure) pack had expired October, 2023, Eleven (11) catheter stabilization devices (PICC Plus) had expired [DATE], Forty-three (43) specimen collection kit swabs (throat cultures) had expired [DATE], (300 + 6) Accuchek Fast Clix (lancing devices) had expired Nov. 2021, (100) 3 cc [NAME] syringe without needles had expired [DATE], Five [NAME] Control Solution for glucose test strips, 3 milliliters, 1 per box, had…

    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 · D2023-10-27 · 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 dietetic staff observations, dietary staff interview and departmental document review the facility failed to ensure employment of a full-time qualified individual to manage and oversee dietary services. Failure to employ staff with the skills and abilities to effectively implement departmental processes in accordance with physician's orders and standards of practice may jeopardize the health and well being of the 30 residents in the facility. Findings: During initial tour of dietetic services on 10/23/23, Dietary Staff 2 (DS 2) indicated the was the cook for the next meal as well as the supervisor for the kitchen staff. It was also noted on the door leading to the office the facility posted a county required food handler's certificate. In an interview with the Registered Dietitian on 10/24/23 beginning at 2:10 PM., the surveyor asked her to describe the qualification for Dietary Staff 2 (DS 2). The RD acknowledged she was aware DS 2 was not qualified to hold the position in accordance with regulatory requirements. The RD also stated while she had approached her to take 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 · D2023-10-27 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide notice of discharge in writing to resident and or family member, when one of 3 discharged residents (Resident 177) did not have discharge summary and notice of discharge in writing before the discharge date . This failure has potential for resident not knowing her appeal rights and not receiving treatment and services due to lack of continuity of care. Findings: Review of Resident 177's admission Record, dated, 10/26/23, indicated, Resident 177 was admitted on [DATE] with diagnoses including: Polymyositis, (a disease that causes the muscles to become irritated and inflamed), Cerebral Infarction (disrupted blood and oxygen supply to an area in the brain), otherwise known as Stroke, Dementia (symptoms of forgetfulness, limited social skills and impaired thinking abilities that interferes with daily functioning). Resident 177 was discharged to home on 4/22/22. During an interview on 10/26/23 at 11:00 AM, with the Director of Nursing (DON), DON…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2021-11-10 · 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 food production observations, resident and dietary staff interview, and dietary document review, the facility failed to ensure meal palatability and menu meets nutritional requirement when: 1. The noon meal on 11/9/21 lacked flavor; 2. The recipes were not followed for two lunch items per the planned menu on 11/9/21 for 23 residents. These deficient practices could negatively affect the caloric and nutrient intake needs of the residents. Findings: 1. During an initial tour interview on 11/8/21 at 10:05 AM, Resident 10 had concerns about food served. Resident 10 stated, Sometimes the food is salty, sometimes it doesn't have taste. I couldn't eat it it's not food appropriate for nursing home . Resident 10 said that staff were aware of the issues. During an initial tour interview on 11/8/21 at 10:12 AM, Resident 25 stated she had concerns regarding the food served. Resident 25 stated, I don't like the food . there's too much sauce on the meatballs . the food is salty . During a concurrent observation and interview with Resident 7 on 11/8/21 at 12:23 PM, in resident's room,…

    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 · F2021-11-10 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    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 its Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) Program when corrective actions were not developed to address issues about food preparation and food palatability (refers to the taste and/or flavor of the food). (Refer to F804) Failure to develop quality assurance plan and corrective actions had the potential to negatively affect the resident's nutrition and hydration status. Findings: Review of the facility's Resident Council Meeting Minutes dated 8/31/21, indicated, . food is cold when served every meal, served too much food, meat served with bone hard to cut . Review of the facility's Quality Assurance and Assessment/Quality Assurance & Performance Improvement, dated 7/15/21 and 10/27/21, indicated, no corrective actions were developed to address the issues/concerns about food being served to the residents. During an interview with the Administrator (ADM) and Director of Nursing (DON) on 11/10/21, at 1:38 PM, the ADM stated the residents' complaint about food…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-11-10 · 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 had an 8.57 % error rate when 3 medication errors out of 35 opportunities were observed during a medication pass for Resident 11 and Resident 13. These deficient practice resulted in medications not given in accordance to the manufacturer's specification which may result in residents not receiving the full therapeutic effect of the medications. Findings: 1. During a medication pass observation, on 11/9/21 at 8:45 AM, Licensed Vocational Nurse (LVN)1, administered Olopatadine Hydrochloride Ophthalmic Solution (a solution indicated for the treatment of signs and symptoms of allergic conjunctivitis) one drop each eye to Resident 13. LVN 1 did not instruct resident to close eyes slowly after the drop and to keep eyes closed for 3 minutes. LVN wiped eyes with tissue, did not compress inner canthus for 1-2 minutes. During an interview on 11/9/21 at 11:40 AM, LVN 1 stated, I did not put pressure on the inner corner of the eye that long. Review of the clinical record for Resident 13 indicated, a physician order dated 6/8/21…

    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 · Ecited before2021-11-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on dietetic services observation, dietary staff interview, and dietary record review, the facility failed to ensure dietetic services were implemented in accordance with facility policy and acceptable standards of practice when: 1. A red bucket with chemical sanitizer was directly adjacent to single-use articles; 2. Scoop for uncooked regular rice was kept inside the bin. These deficient practices had the potential to subject residents to foodborne illnesses. Findings: 1. During the initial kitchen tour observation and concurrent interview on 11/8/21 at 10:00 AM with the Dietary Supervisor (DS), a red bucket containing chemical sanitizing solution with a soaked wiping cloth, was stored inside the cabinet together with clean single-use items such as cups and bowls. The DS acknowledged that the chemical solution in the bucket was used for cleaning surfaces and stated, It (the bucket) should not be kept here with the clean items. Review of facility policy titled Sanitation indicated, .Procedure .21. The FNS (Food & Nutrition Service) Director is responsible for instructing…

    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 before2021-11-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide supervision for safe smoking for one of 12 sampled residents (Resident 11). The deficient practice had the potential to result in accidents, including burns, harm and even death. Findings: Resident 11 was admitted on [DATE], with diagnoses including hypotension (low blood pressure), nontraumatic intracerebral hemorrhage (a life-threatening type of stroke caused by bleeding in the brain), diabetes mellitus (high blood sugar), and muscle weakness. During a review of the clinical record for Resident 11, the Smoking-Safety Screen dated 8/18/21 indicated, resident smoke two to five cigarettes per day and like to smoke in the morning and afternoon. The Smoking-Safety Screen indicated, . 8.resident need facility to store lighter and cigarettes . F. IDTC DECISION: resident requires supervision on smoking time . Safe to smoke with supervision . Alert and oriented but requires supevision. During an observation on 11/8/21, at 12:40 PM, at…

    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 before2021-11-10 · tag F0802 — failed to prepare enough nourishing food — isolated
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the competency of one kitchen staff (KS) when the standardized recipes were not followed during the noon meal on 11/9/21. Findings: During an observation of food production activities on 11/9/21 beginning at 9:51 AM, Kitchen Staff (KS) did not consistently follow recipes (Cross Reference F804). In an interview on 11/10/21 at 9:46 AM with the Dietary Supervisor (DS), DS described guidance to dietary staff as informal discussions during food production activities if issues or concerns are observed. DS stated, I check everything what my staff do. Training documents were requested and review of training records revealed there was no documented in-service training related to preparing and following standardized recipes. DS said that in-service training will be given later that day.

    Nutrition and Dietary 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.

Who owns this facility

Owner / managerTypeRoleShareSince
ST. THERESE CONVALESCENT HOSPITAL ,INC.Organization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2003
CABANAYAN, DANILOIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; GENERAL PARTNERSHIP INTEREST50%since 07/01/2003
CABANAYAN, LORETAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 07/01/2003

CMS files one row per role, so the 7 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$4.6M
Net patient revenuemost recent cost report
-7.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 11%Other / private 89%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$530per resident / day
operating cost
$16,126per month
≈ monthly operating cost
$495per 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 555813. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-17, 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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