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Bethany Home Society San Joaquin County

930 West Main Street, Ripon, CA 95366 · Non profit - Corporation · 92 certified beds · (209) 599-4221 Medicare & Medicaid certified

Call the home — (209) 599-4221 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Mar 2025Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2025
  • a high number of inspection citations overall (29) — 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) 3 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
150 Vera Ave · (209) 599-4211 · Call to confirm hours
Pharmacy
1201 W Main St · (209) 599-4686 · Call to confirm hours
Grocery
223 W Washington St · (209) 599-5403 · Call to confirm hours
Park
334 W 4th St · 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 3 of 5

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

Trend — is this home getting better or worse?

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

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

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 increased12.8%10.2%15.4%better
Long-stay residents who lose too much weight1.7%4.0%5.4%better
Long-stay residents with a catheter left in their bladder1.5%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.5%1.2%2.0%better
Long-stay residents with depressive symptoms2.5%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 injury1.8%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication8.4%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers3.9%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control23.1%10.2%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table4.5%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.7%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine98.0%93.2%79.4%better
Short-stay residents rehospitalized after admission25.7%23.0%22.6%worse
Short-stay residents with an outpatient ER visit14.4%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.432.251.67better
Long-stay outpatient ER visits per 1,000 resident days0.361.571.80better

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.

63.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 105 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.9%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
47.5%U.S. median 56.6%
Met the expected recovery
0.05U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy

Met the expected recovery: 47.5% 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 40 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 0.05 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 51% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.9%CMS range 54.8–71.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 6.5–15.210.7%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 discharge47.5%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 discharge35.0%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 discharge35.0%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 identified98.0%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 hospitalization7.3%CMS range 4.0–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.761.02Oct 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

0.35
RN hours/ resident / day
1.26
LPN hours/ resident / day
2.70
Aide hours/ resident / day
4.31
Total nurse hours/ resident / day
0.26
RN hoursweekends
46.4%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 92 beds and averages 56.0 residents a day — about 61% occupied, or roughly 36 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.31 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.70 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 3.88 hrs/resident/day on weekends vs 4.49 on weekdays — 13% thinner on weekends. RN hours go from 0.38 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

4
deficiencies at the latest standard inspection (2025-03-21)
6
at the previous standard inspection (2022-11-04)

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.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · Dcited before2026-04-15 · 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 ensure two of three residents (Resident 5 and Resident 8) were provided with a safe environment when:1. Resident 5 eloped (a resident leaving the premises or a secure area without authorization, supervision, or the knowledge of the staff) from the facility2. The C Hall exit door did not have an alarm activated during the day3. Resident 5 and Resident 8's [Brand Name] elopement bracelets (bracelet that can be placed on a resident and sets off a door alarm when the resident tries to exit through the door) were not checked at least daily for placement and function and not all exit doors at the facility were alarmed. These failures resulted in Resident 5 leaving the facility unsupervised and had the potential for Resident 8 to leave the facility unsupervised, with the potential for both Resident 5 and Resident 8 to experience getting lost and sustaining injuries, which had the potential to negatively affect their health, well-being, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-15 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure one of three sampled residents' (Resident 1) drug regimen (a structured, prescribed plan for taking medication) was appropriately followed when Resident 1's prescribed narcotic pain medication (a strong, addictive, a regulated pain medication) that was prescribed for moderate to severe pain every six hours, was given without assessing Resident 1's pain level (the numerical pain scale 0 through 10; 0 indicates no pain,1 through 3 indicates mild pain; 4 through 6 indicates moderate pain; 7 through 10 indicates severe pain).This failure had the potential to result in Resident 1 being over-medicated and placed Resident 1 at risk for falls, negatively affecting Resident 1's health and well-being. Findings:A review of Resident 1's clinical document titled, admission RECORD, date printed 4/15/26, indicated Resident 1 was admitted to the facility with diagnoses which included dementia (a decline in brain function that interferes with daily life, usually caused by progressive, irreversible brain damage) and osteoporosis (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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-15 · 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

    Based on interview and record review the facility failed to maintain complete and accurate records for one of two sampled residents (Resident 1) when Resident 1's document titled, Weekly Summary, (a weekly review of the resident's condition) for the week ending in 3/25/226, did not reflect Residents 1's current health status.This failure resulted in an inaccurate representation of Resident 1's current health status and had the potential to negatively impact Resident 1's health regarding wounds and pain management. Findings:A review of Resident 1's clinical document titled, admission RECORD, date printed 4/15/26, indicated Resident 1 was admitted to the facility with diagnoses which included dementia (a decline in brain function that interferes with daily life, usually caused by progressive, irreversible brain damage) and osteoporosis (a common bone disease making bones thin, brittle, and highly prone to fractures).A review of Resident 1's clinical document titled, Weekly Summary, dated 3/25/26, indicated, A. Skin Assessment . No wounds currently . Site . buttock . Type . MASD…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-08 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure safe monitoring practices for high-risk medication (drugs with potential to cause harm without monitoring) use in one out of four residents (Resident 1) when:1. Resident 1 was prescribed metoprolol (a medication used to control heart rate and rhythm) without orders to monitor Resident 1's blood pressure or heart rate; and2. Resident 1's experienced syncopal episodes (a brief loss of consciousnesses caused by a temporary decrease in blood flow to the brain) during transfers, which were not adequately documented or addressed by the licensed nurse (LN).These failures had the potential to result in unsafe medication use and adverse consequences for Resident 1.1. Review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with diagnoses that included but was not limited to atrial fibrillation (A-Fib; heart rhythm disorder) and hypertension (HTN; high blood pressure). During a concurrent interview and record review on 9/5/25 at 2:33 PM, Resident 1's Order Summary Report, dated 9/25 and Blood…

    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 · D2025-09-08 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 restorative nursing program (RNP-nursing intervention to increase or maintain resident's mobility and to prevent further decline in mobility) for one of four sampled residents (Resident 1) when the RNP plan of care for passive range of motion (PROM - the movement of a joint through the range of motion with no effort from the patient) exercises to Resident 1's upper extremities was not revised following a right shoulder dislocation and fracture.This failure placed Resident 1 at risk for further injury, pain and discomfort to the right shoulder and right arm.Findings:During a review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses that included but were not limited to dementia (a decline in mental ability severe enough to interfere with daily life), displaced fracture of upper end of right humerus (arm bone), and unspecified dislocation of right shoulder (when the ball shaped head of the humerus bone (upper arm) comes out of the socket in the shoulder…

    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 · D2025-07-18 · 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 a comprehensive elopement (leaving a designated area, often a place of supervision or care, without permission) risk care plan (a guide that healthcare workers used to ensure Resident 1 received tailored care to his/her individual needs and goals) for one of two residents at risk for elopement (Resident 1), when Resident 1 was seen by facility staff sitting outside of the building unattended.This failure placed Resident 1 at risk for elopement and injury. Findings:During a review of Resident 1's clinical record titled, admission RECORD, (a document that contained the resident's demographic information) indicated Resident 1 was admitted to the facility with a diagnoses that included Dementia (a condition which caused a decline in memory, reasoning, and other thinking skills), tremors (shaking), dizziness, and hypertension (high blood pressure - the force of blood pushing against the artery walls).A review of Resident 1's clinical record titled, BRIEF INTERVIEW FOR MENTAL STATUS, (BIMS - a screening tool used to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-18 · 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

    Based on observation, interview, and record review, the facility failed to ensure adequate supervision for one of two sampled residents (Resident 1), at risk for elopement (leaving a designated area, often a place of supervision or care, without permission), when Resident 1 was found outside of the physical therapy office back door on 5/27/25 at approximately 5:00 p.m.This failure placed Resident 1 at risk of serious injury and harm.Findings:During a review of Resident 1's clinical record titled, admission RECORD, (a document that contained the resident's demographic information) indicated Resident 1 was admitted to the facility with a diagnoses that included Dementia (a condition which caused a decline in memory, reasoning, and other thinking skills), tremor (shaking), dizziness, and hypertension (high blood pressure- the force of blood pushing against the artery walls).A review of Resident 1's clinical record titled, Progress Notes, dated 5/27/25 at 10:37 p.m., written by the Licensed Nurse (LN) 1, indicated at approximately 5:00 p.m., Resident 1 was found outside by the physical…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-21 · tag F0761 — failed to label and store drugs safely — pattern
    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

    Based on observation, interview, and record review, the facility failed to ensure documentation and monitoring of temperature range in one out of one medication refrigerator for a period of 6 months with resident census of 63. This failed practice may have contributed to unsafe storage of refrigerated medication resulting in altered potency and unusable medications based on manufacturer specification. Findings: During a concurrent observation and interview on 3/18/25, at 9:20 AM, with Licensed Vocational Nurse (LN) 4, the refrigerator at North hall station stored multiple containers of flu vaccine (flu same as influenza, an infection affecting the breathing system), resident's insulin (medication used to treat blood sugar disease), other refrigerated prescription medications, and Emergency Kit (or Ekit, a sealed container containing insulin and other refrigerated products for urgent use). The thermometer inside the refrigerator was within the approved and safe temperature range (36-to-46-degree Fahrenheit [a measure of temperature]). LN 4 was unable to provide North hall station…

    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 · D2025-03-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a resident's right to be free from verbal abuse for one of sixteen sampled residents (Resident 44) when, Resident 44 was cursed at by Licensed Nurse (LN) 5. This failure had the potential to cause emotional distress and could negatively affect Resident 44's psychosocial well-being. Findings: Review of Resident 44's admission RECORD, indicated Resident 44 was admitted with diagnoses including depression (mental health condition characterized by persistent feelings of sadness) and anxiety (persistent worry) disorders. Review of Resident 44's Minimum Data Set [an assessment tool], dated 2/4/25, indicated Resident 44's Brief Interview for Mental Status score was 13 out of 15 suggesting an intact cognitive functioning (a person's mental processes, including thinking, learning, memory, and reasoning, are functioning normally and without any significant impairment). Review of Resident 44's IDT [Interdisciplinary Team; a group of healthcare professionals] Note, dated 11/13/24, indicated, .On 11/1/2024…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-21 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure the safe use of psychotropic medications (mind altering drugs used to control behavior or thought process) for two of five sampled residents (Resident 44 and Resident 52) reviewed for unnecessary medications use when: 1. The physician did not document specific duration for the extended use of the as needed (or PRN) lorazepam (or Ativan, a psychotropic medication for anxiety) beyond 14 days for Resident 52. 2. There was no documented evidence of non-pharmacological interventions (means helping residents with behavioral issue without use of the drugs) for Resident 44 and Resident 52 while taking psychotropic medications for treatment of anxiety. These failures had the potential for unsafe use of psychotropic medications resulting in negative impact or adverse drug effects on Resident 44's and Resident 52's health. Findings: 1. During a concurrent interview with Licensed Vocational Nurse (LN) 3, and record review of Resident 52's medical record, on 3/20/25, at 9:18 AM, LN 3 confirmed Resident 52's order for a routine…

    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
Show the remaining 19 citations
  • Potential for harm · D2025-03-21 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 residents receiving regular chicken pot pie received the appropriate nutritive content as prescribed by a physician when serving sizes were smaller than ordered for 19 residents with a census of 63. This failure had the potential of leading to malnutrition and weight loss for the 19 residents receiving a regular diet. Findings: During an observation of the lunch meal on 3/19/25, at 11:15 a.m., the service utensils were noted for the various foods. The steamed regular broccoli was noted to have a gray handled spoodle (unique cross between a serving spoon and a ladle which allows to efficiently scoop and serve just the right amount of food). The mashed potatoes was noted to have a blue handled spoodle. The chicken pot pie was noted to have a black handled spoodle placed in the pan and was used to scoop the chicken pot pie during the meal plating for the residents on the first food cart. During a review of the undated facility provided cook's spread sheet indicated the serving amounts for the regular…

    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 · D2023-10-24 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 interview and record review, the facility failed to notify the Medical Director (MD) in a timely manner with a change of condition for one of 24 sampled residents (Resident 1) when Resident 1 fell and sustained a visible injury and possible non-visible injuries. This failure resulted in the MD not having immediate knowledge of the fall and/or the opportunity to order new treatment which could have provided comfort to Resident 1 and/or prevented his subsequential death. Findings: During a review of the facility's document titled, Discharge Summary, dated [DATE], at 3:20 PM, by the Nurse Practitioner (NP), indicated, Resident 1 had a fall at [MEMORY CARE FACILITY NAME]. Prior to the fall, Resident 1 was on Eliquis (blood thinning medication to reduce blood clots) for Atrial fibrillation (A-Fib, an irregular, rapid heart rhythm that can lead to blood clots in the heart and cause a stroke [when something blocks blood supply to the brain]). Resident 1 was brought in by ambulance to [ACUTE CARE HOSPITAL NAME]…

    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 before2023-10-12 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to follow physician orders for one of three residents sampled (Resident 1) when Resident 1's order to monitor right lower extremity (leg) circulation, motion, and sensation (CMS) was not followed. This failure had the potential for Resident 1 to suffer impairment of the soft tissues and nerves in her right lower extremity which could potentially cause permanent damage to her limb. Findings: A review of Resident 1's admission RECORD, indicated she was readmitted to the facility in September 2023 with diagnoses which included fracture of lateral malleolus of right fibula (break of an ankle bone). A review of Resident 1's care plan initiated 10/2/2023, indicated, Problem .I have a right lateral malleolus fracture .Goal .the resident will not develop complications or permanent loss of mobility related to fracture . Interventions .soft splint in place to right ankle/lower leg-check CMS q [every] shift . A review of Resident 1's Order Details, dated 9/29/23, indicated, .soft splint in place to right ankle/lower leg-check CMS q…

    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 · D2023-10-04 · 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

    Based on interview and record review, the facility failed to update one (1) of two resident's (Resident 1) care plan (a document that contains the resident's individualized problems, goals, and interventions) following Resident 1's four elopements (a vulnerable resident who leaves a facility unnoticed) from the facility during the night shift (11:00 PM through 7:00 AM) on 9/30/23. This failure resulted in the facility continuing to utilize ineffective interventions which jeopardized the health and safety of Resident 1, which could have resulted in injury or death. Findings: A review of Resident 1's clinical record titled, admission RECORD (a document that contains the resident's demographic information) indicated, Resident 1 was admitted to the facility with a diagnosis of sepsis (overwhelming infection) and Dementia (a condition which causes a decline in memory, reasoning, and other thinking skills). A review of Resident 1's clinical record titled, Progress Notes, dated 10/1/23 at 7:29 AM, by Licensed Nurse (LN 1), indicated, during the night shift of 9/30/23, Resident 1 eloped…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-04 · 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

    Based on observation, interview, and record review, the facility failed to ensure adequate supervision for one (1) of two residents (Resident 1) at risk for elopement (a vulnerable resident who leaves a facility unnoticed) when Resident 1 left the facility four times during the night shift (11:00 PM - 7:00 AM) on 9/30/23 through 10/1/23. This failure jeopardized the health and safety of Resident 1, which could have resulted in injury or death. Findings: A review of Resident 1's clinical record titled, admission RECORD (a document that contains the resident's demographic information) indicated, Resident 1 was admitted to the facility with a diagnosis of sepsis (overwhelming infection) and Dementia (a condition which causes a decline in memory, reasoning, and other thinking skills). A review of Resident 1's clinical record titled, Progress Notes, dated 10/1/23 at 7:29 AM, by Licensed Nurse (LN 1), indicated, during the night shift of 9/30/23, Resident 1 eloped from the facility multiple times. The first incident was on 9/30/23 at 11:30 PM when Resident 1 eloped from the Hall B's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-22 · 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 implement a fall intervention for one of two sampled residents (Resident 1) when a fall mat was not placed on the floor while Resident 1 was in bed. This failure had the potential for Resident 1 to sustain further injuries due to a fall. Findings: During a review of Resident 1's admission Record, indicated Resident 1 had diagnoses of osteoporosis (a medical condition in which bones become weak and brittle) and fracture (a break in the bone) of the right shoulder. During a review of Resident 1's Minimum Data Set, (MDS-an assessment tool) dated 7/20/23, the MDS indicated Resident 1 scored 8 out of 15 in a Brief Interview for Mental Status (BIMS) which suggested Resident 1 had moderate cognitive impairment (reasoning, understanding and memory are affected). During a review of Resident 1's Fall Risk Form, (an assessment tool to determine fall risk factors and target interventions to reduce risks) dated 7/7/23, indicated Resident 1 scored 75.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-11-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 ensure a safe and hazard free environment for a census of 50 when: 1. Safe water temperatures were not maintained in resident restrooms for 3 out of 5 halls (Hall A, Hall B, and Hall C) in the facility; and, 2. Fall interventions were not implemented for 3 of 21 sampled residents (Resident 22, Resident 23, and Resident 49), when a fall mat was not placed on the floor at bedside for Resident 22, Resident 23, and Resident 49. These failures had the potential to cause physical harm to the residents in the facility. Findings: 1. During a concurrent observation and interview on 11/3/22, at 2:27 p.m., with the Maintenance Director (MAIN) in Hall B, the MAIN confirmed the sink hot water temperatures were measured ranging from 129.4- 129.6 degrees Fahrenheit (F-scale for measuring temperature) for resident rooms 10, 11, 12, 13, 14, 15, 16, 17, 18 and 19. The MAIN stated the sink hot water temperatures were too hot and the hot water temperature…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-11-04 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation, and record review the facility failed to ensure high risk medications (with potential to cause harm without careful monitoring) for diabetes (a disease that affect blood sugar) and a blood thinner (could cause bleeding) were monitored for possible adverse effects in two out of 21 sampled residents (Resident 10 and Resident 23). These failures had the potential to affect safe medication monitoring by licensed staff. Findings: 1. During a medication pass observation on 11/1/22, at 9:21 AM, accompanied with Licensed Nurse 4 (LN 4), in facility's hall A, LN 4 administered a medication called Eliquis (also known as Apixaban, a blood thinner) to Resident 10 for a heart problem. LN 4 did not look for any sign or symptoms of bleeding or bruising. During a review of Resident 10's electronic medical record titled Medication Administration Record (or MAR, a list of medications and interventions nursing staff followed and documented), with date ranges of 10-1-22 to 10-31-22 and 11-1-22 to 11-30-22, the MAR did not show any nursing monitoring order 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 · Ecited before2022-11-04 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a system was in place to monitor psychotropic medications (mind altering drugs) for adverse effects in two out of 21 sampled residents (Resident 11 and Resident 40). These failures had the potential to affect safe medication use and monitoring by licensed staff. Findings: 1. During review of Resident 11's electronic medical record titled Medication Administration Record (or MAR, listed medications and interventions nursing staff followed and documented), with the date range of 10/1/22 to 10/31/22, the MAR indicated the following psychotropic medication were administered on a daily basis: a. Abilify Tablet 2 MG (known as Aripiprazole, mind altering medication for mood); MG is milligram and a unit of measure); Give 2 mg by mouth at bedtime for . Depression disorder M/B [manifested by] frequent tearfulness, sad facial expressions, loss of appetite; Start Date-10/19/22. b. Mirtazapine (medication used to help mood and appetite) Tablet 7.5 MG; Give 1 tablet by mouth at bedtime for Depression M/B sad facial expressions,…

    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 before2022-11-04 · tag F0761 — failed to label and store drugs safely — pattern
    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

    Based on interview, observation, and record review the facility failed to ensure safe medication storage practices when: 1. Outdated medication and supplies were stored in the active storage areas in one out of one medication storage room. 2. Emergency kit (or Ekit, a sealed and labeled medication box for emergency use) labeled as Ear and Eye Emergency Kit contained an outdated eye medication in one out of two inspected Ekits. 3. Refrigerated vaccines were stored with food items and the temperature was not monitored twice daily in one out of four medication refrigerators. These failures had potential for medication error and unsafe medication use. Findings: 1. During a concurrent observation and interview on 11/1/22, at 10:09 AM, accompanied by Licensed Nurse (LN )1, in the facility's medication room, the following outdated medication and supplies were noted in the locked storage cabinet. LN 1 acknowledged the findings as follows: a. Glucometer (a machine that measures blood sugar) control solution (solution used to calibrate the glucometer machine), brand name McKesson True Matrix…

    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 before2022-11-04 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy review, the facility failed to maintain cleanliness of the ice machine for a census of 50. This failure had the potential for the residents in the facility to receive water and ice with contaminants that could lead to water borne illness. Findings: During an observation of the facility's ice machine in the west dining area with Dietary Manager (DM) on 11/2/22, at 11:00 a.m., maintenance staff opened the ice machine. The panel in front of the ice grid was removed. Surrounding the grid perimeter were brown/ black markings of approximately ¼ inch (unit of measurement) thickness.The center of the panel covering the ice grid had similar brown/black marks of approximately ¼ inch thickness.The DM acknowledged the markings. During an interview on 11/3/22, at 12:03 p.m., with the Administrator (ADM) confirmed that the maintenance department had no cleaning log for the ice machine. During an interview on 11/3/22, at 1:39 p.m., with the Infection Preventionist (IP), the IP stated the ice machine was used by both staff and residents. The IP…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-11-04 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe infection control practices for a census of 50 residents when: 1. Licensed staff did not perform hand hygiene with hand sanitizer or soap and water while providing care during medication administration for Resident 3 and Resident 25. 2. Medication tray (small tray used to carry medication and supplies into residents' rooms) was not sanitized in-between resident care for Resident 3 and Resident 25. 3. Two direct care staff members did not wear the required personal protective equipment (PPE, includes gowns, gloves, eye protection, facemasks or respirators worn to prevent the spread of germs and infection) when providing care to residents on transmission-based precautions (TBP- infection control precautions for known or suspected infectious agents). These failures had the potential to spread infection in the facility. Findings: 1. During a medication pass observation on 11/02/22, at 4:00 PM, accompanied by Licensed Nurse (LN) 3,…

    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 · F2019-05-09 · tag F0755 — failed to provide safe pharmacy services — widespread
    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 observations, staff interviews, and record review, the facility failed to: 1. Ensure proper disposition of medication when a container with medications, under a sink, in an unlocked storage room was accessible to anyone for a census of 79. This failure had the potential for staff, visitors, and residents to ingest the medication resulting in an overdose or death. 2. Ensure the medication administration route for bisacodyl suppository (a laxative administered rectally) was specified in the physician's order and medication administration record (MAR) for 17 of 25 sampled residents (Resident 5, Resident 9, Resident 10, Resident 17, Resident 18, Resident 22, Resident 28, Resident 31, Resident 34, Resident 35, Resident 50, Resident 54, Resident 55, Resident 57, Resident 59, Resident 68, and Resident 77). This failure placed Resident 5, Resident 9, Resident 10, Resident 17, Resident 18, Resident 22, Resident 28, Resident 31, Resident 34, Resident 35, Resident 50, Resident 54, Resident 55, Resident 57, Resident 59, Resident 68, and Resident 77 at potential risk for a medication…

    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 · Fcited before2019-05-09 · 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, interviews, and facility document review, the facility failed to maintain sanitary conditions during a meal preparation when a kitchen aide entered and walked around the kitchen without her hair being covered for a census of 79. This failure had the potential for food to be contaminated, placing the residents at risk of getting a food borne illness. Findings: During the Initial Tour of the kitchen on 5/6/19, at 7:45 a.m., the dietary supervisor (DS) stated when anyone enters the kitchen they are to put on a hair net. During an observation on 5/8/19, at 11:37 a.m., a female entered the kitchen through a door connected to a facility hallway. She walked from the door, the full length of the kitchen to the DS's office, passing the food holding area where lunch was being prepped, exited the office and then walked back the full length of the kitchen to a hallway next to the door she entered. She was not wearing any form of head covering to contain her hair. In an interview on 5/8/19, at 11:43 a.m. with the female (kitchen aide), who entered the kitchen with no head…

    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 · E2019-05-09 · tag F0623 — pattern
    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 staff interviews and clinical record review, the facility failed to notify the local Long-Term Care (LTC) Ombudsman (advocate) of the residents' transfer to the local emergency room (ER) for 4 of 41 sampled residents, (Resident 51, Resident 5, Resident 73, and Resident 17). This failure denied Resident 51, Resident 5, Resident 73, and Resident 17 of the added protection of having the LTC Ombudsman being made aware of their transfer from the facility. Findings: Clinical record reviews revealed the following residents were transferred from the facility to the local ER: a. Resident 51 was transferred from the facility to the local ER on [DATE] and 4/12/19; b. Resident 5 was transferred from the facility to the local ER on [DATE] and 4/8/19; c. Resident 73 was transferred from the facility to the local ER on [DATE] and 4/5/19; and d. Resident 17 was transferred from the facility to the local ER on [DATE]. Further clinical record review revealed there was no documented evidence that a notice 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 · Ecited before2019-05-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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

    Based on observations and interviews, the facility failed to ensure proper storage of and allowed access to chemicals when a liquid drug deactivation container (Brand Name product that uses activated charcoal to neutralize the chemicals in pills, liquids, controlled substances and transdermal patches) was stored on the outside of three medication carts for a census of 79. This failure had the potential for staff, visitors, and residents to ingest the liquid charcoal, resulting in vomiting, and skin or eye irritation. Findings: During a concurrent medication pass observation and interview on 5/8/19 at 8:25 a.m., licensed nurse (LN) 2 was administering medications to Resident 18. LN 2 was reviewing the medications with Resident 18. Resident 18 had a calcium with vitamin D tablet in her hand and stated to LN 2 that she did not want to take it; the tablet then fell on the floor. LN 2 picked up the medication and stated she would place it in the container with the [Brand Name] drug deactivation liquid. The container was located on the left side of the medication cart approximately 10…

    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 · D2019-05-09 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on staff interview and document review, the facility did not provide 1 of 3 sampled residents (Resident 75) a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). This failure placed Resident 75 at risk of not being informed of their responsibility to pay for any services received after their Medicare coverage ended. Findings: During a concurrent interview and record review with the executive director (ED) on 5/9/19 at 11:07 a.m., she verified Resident 75 was not provided a SNF ABN after her Medicare coverage ended. The ED acknowledged she was unaware that Resident 75 should have received a SNF ABN and stated it will be corrected.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-09 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) for 1 of 41 sampled residents (Resident 68) accurately reflected the resident's functional status (individual's ability to perform activities of daily living [ADLs]). This failure had the potential for Resident 68 to receive inaccurate care. Findings: Resident 68 was admitted to the facility with diagnoses which included dementia (a decline in mental ability) and abnormalities of gait and mobility. Resident 68 was observed sitting in a geri chair (recliner chair with wheels) while in the dining room on 5/6/19, at 11:30 a.m. Resident 68 did not move their geri chair on their own; staff moved the geri chair for Resident 68. A review of Resident 68's clinical record revealed the following: 1) A licensed nurse weekly summary dated 11/12/18, indicated, .Transfers with a total lift and assist of one. Uses a wheelchair for mobility. Pushed by staff . 2) Section G of the 11/13/18 MDS (used to assess functional status of the resident) showed Section G0110B1…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-05-09 · 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, staff interviews, and record review, the facility failed to implement its infection control program for 6 residents (Resident 12, Resident 34, Resident 36, Resident 40, Resident 41, and Resident 49) out of a census of 79 when staff did not perform proper hand hygiene while assisting residents with meals. This failure had the potential to spread infection to Resident 12, Resident 34, Resident 36, Resident 40, Resident 41, and Resident 49. Findings: 1. During dining observation on 5/6/19, at 12:22 p.m., certified nurse assistant (CNA) 1 touched Resident 68's pillow and geri chair (recliner chair with wheels) to assist another CNA to properly position Resident 68 for lunch. After touching Resident 68's pillow and geri chair, CNA 1 assisted Resident 34 to eat without performing hand hygiene first. In an interview with CNA 1 on 5/6/19, at 12:56 p.m., she stated she should have washed her hands after touching Resident 68's pillow and geri chair. 2. In a dining observation on 5/6/19, at 12:26 p.m., licensed nurse (LN) 3 touched a female resident's wheelchair to move…

    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

“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 / managerTypeRoleSince
ALGER, RAEANNIndividualMANAGING CONTROL - GOVERNING BODYsince 02/25/2025
FIEN, ELISABETHIndividualMANAGING CONTROL - GOVERNING BODYsince 02/25/2025
MILLER, JEFFIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/25/2022
MULDER, WILLIAMIndividualMANAGING CONTROL - GOVERNING BODYsince 01/30/2024
OSBORN, CLAIREIndividualMANAGING CONTROL - GOVERNING BODYsince 01/30/2024
SLAGER, CAROLIndividualMANAGING CONTROL - GOVERNING BODYsince 01/29/2019
VAN ESSEN, RONALDIndividualMANAGING CONTROL - GOVERNING BODYsince 01/31/2023
VAN GRONINGEN, JEFFREYIndividualMANAGING CONTROL - GOVERNING BODYsince 01/31/2023
VAN TILL, JOHNIndividualMANAGING CONTROL - GOVERNING BODYsince 01/31/2023
VANDER PLAATS, JUDITHIndividualMANAGING CONTROL - GOVERNING BODYsince 01/30/2024
VEILLEUX, JEFFREYIndividualMANAGING CONTROL - GOVERNING BODYsince 02/25/2025
VERMEULEN, TOMIndividualMANAGING CONTROL - GOVERNING BODYsince 01/31/2020
DUTTER, DARYLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/31/2006
MARCUS, STEVEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/12/2026
SCHEUBLEIN, CINDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2015
SHARMA, VIJAYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/31/2022

CMS files one row per role, so the 21 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$9.7M
Net patient revenuemost recent cost report
-47.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 33%Medicare 4%Other / private 62%

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

$431per resident / day
operating cost
$13,107per month
≈ monthly operating cost
$292per 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 055662. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-21, 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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