Riverside Heights Healthcare Center, LLC
8951 Granite Hill Drive, Riverside, CA 92509 · For profit - Partnership · 70 certified beds · (951) 685-7474 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.2% | 10.2% | 15.4% | typical |
| Long-stay residents who lose too much weight | 5.6% | 4.0% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.9% | 1.2% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.4% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.4% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 12.2% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.1% | 13.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.5% | 4.3% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 3.9% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.2% | 12.0% | 17.1% | worse |
| Short-stay residents rehospitalized after admission | 40.2% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.5% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 5.32 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.73 | 1.57 | 1.80 | worse |
‡ 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.
Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 36% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.3%CMS range 6.1–14.1 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.9% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.4%CMS range 5.6–14.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.30 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 70 beds and averages 67.2 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 4.17 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.74 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.79 hrs/resident/day on weekends vs 4.32 on weekdays — 12% thinner on weekends. RN hours go from 0.49 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · D2025-06-20 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 identify adverse effects of psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) for one of six residents reviewed (Resident 44), when Resident 44 was administered Risperdal (an antispychotic medication) and was observed with a facial chewing motion. This failure had the potential for Resident 44 to have irreversible adverse effects such as extrapyramidal symptoms (EPS, movement disorders caused by certain medications, particulary antipsychotics). Findings: On June 16, 2025, at 12:04 p.m., Resident 44 was observed having a facial chewing motion while sitting at a table in the dining room. On June 18, 2025, at 1:50 p.m., a second observation of Resident 44 was conducted. Resident 44 was observed having a facial chewing motion while sitting in the dining room awaiting the start of an activity. A review of Resident 44's medical record was conducted on June 18, 2025. The medical record…
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.
- Potential for harm · Dcited before2025-06-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one of two residents reviewed for oxygen administration (Resident 20), when the physician's order for oxygen administration was not followed. This failure had the potential to result in respiratory distress and decline in the resident's health condition. Findings: On June 16, 2025, at 10:45 a.m., Resident 20 was observed in his room, in bed, with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 20 was unable to communicate. Resident 20's oxygen administration was observed at 2.5 liters per minute (LPM - a unit of measurement). On June 18, 2025, at 9:12 a.m., Resident 20's record was reviewed. Resident 20 was re-admitted to the facility on [DATE], with diagnoses which included seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), Huntington's disease (an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-20 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 18) was free from unnecessary medications when Resident 18 received an antihypertensive medication (used to manage high blood pressure) outside of the prescribed blood pressure (BP) parameter four times in April 2025. This failure increased the potential for Resident 18 to experience side effects such as low BP, leading to further heart related complications. Finding: A review of Resident 18's admission Record, dated June 19, 2025 indicated the resident was initially admitted to the facility on [DATE] and recently readmitted on [DATE] with diagnoses including hypertension (high blood pressure), heart failure (serious condition when heart does not pump blood to the body efficiently), and cardiomyopathy (disease of the heart muscle), and atrial fibrillation (abnormal heart beat). A review of Resident 18's Care Plan Report, dated May 8, 2025, indicated the resident was at risk for hypotension (low BP) 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.
- Potential for harm · D2025-06-20 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 a medication error rate of 8% when two medication errors occurred out of 25 opportunities during the medication administration for two of four residents (Residents 28 and 52). The facility did not administer the residents' prefilled insulin (medication for diabetes) pen injection according to the manufacturer's instructions. This failure had the potential to result in Residents 28 and 52 not receiving the full therapeutic benefit of their medications. Findings: 1a. During a medication pass observation on June 18, 2025, at 11:35 a.m., Licensed Vocational Nurse (LVN) 2 was observed preparing a prefilled Humalog (insulin lispro, brand name: Humalog KwikPen, medication for diabetes) 100 units/milliliter (ml, unit of measurement) pen for Resident 28. On June 18, 2025, at 11:39 a.m., LVN 2 was observed administering 4 units from the prefilled Humalog pen as a subcutaneous (under the skin) injection in Resident 28's lower right abdomen. LVN 2 pressed and immediately released the prefilled Humalog pen's dose knob without…
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.
- Potential for harm · Dcited before2025-06-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 refrigerated medications and biologicals were stored at temperatures in accordance with facility policy and manufacturer's specifications when one of two medication refrigerators was identified with documented temperature readings below the normal range on multiple days between January to June 2025. This failure had the potential for residents to receive ineffective medications which could result in the residents not receiving the full benefit of the medications, leading to further health complications. Findings: During a concurrent observation and interview at nursing station 1 on June 16, 2025, at 2:15 p.m. with Registered Nurse (RN) 1, a medication refrigerator was identified. The refrigerator was observed to contain the following medications: - Afluria (flu vaccine) injectable suspension; - Latanoprost (used to lower pressure in the eye) eye drops; - Ozempic (used for diabetes and weight loss) prefilled pen; - Retacrit (used to produce more red blood cells) vial; - various types of insulin (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.
- Potential for harm · Dcited before2025-06-20 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 provide safe storage, preparation, and distribution of food when the kitchen staff performed the chlorine (a sanitizing solution) testing of the dishwashing machine with expired test strips. This failure had the potential to result in foodborne illness to a vulnerable facility population. Findings: On June 18, 2025, at 11:26 a.m., a concurrent observation and interview was conducted with the dietary aide (DA). The DA was observed to run the dishwasher and performed the chlorine test strip. The vial containing the test strips was observed with an expiration date of May 1, 2025. The DA stated the chlorine test strips were expired and should not have been used to test the level of the sanitizing solution from the dishwasher. On June 18, 2025, at 11:35 a.m., an interview was conducted with the Dietary Supervisor (DS). The DS stated the chlorine test strips were expired and should not have been used to test the level of the sanitizing solution from the dishwasher. On June 20, 2025, at 11:21 a.m., an interview was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-20 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 2. On June 16, 2025, at 9:35 a.m., Resident 18 was observed lying in bed, awake, alert, and able to make his needs known. Resident 18 was receiving oxygen (O2) at 3 LPM (liters per minute - a unit of measurement) via the nasal cannula attached to an O2 concentrator (a machine that supplies oxygen). The nasal cannula was labeled with Resident 1's name, room number and date of 6/6/25. A wheelchair was observed at the foot of Resident 18's bed. Resident 18 stated he was using the wheelchair when he was up. An O2 cannula with no date was observed attached to a portable O2 tank. The O2 cannula was observed hanging on the back of the wheelchair, exposed to the environment. On June 16, 2025, at 9:46 a.m. Registered Nurse (RN) 2 was observed assisting Resident 18 in the room. In a concurrent interview with RN 2, she stated Resident 18's nasal cannula was dated 6/6/25. RN 2 stated she was not sure when the O2 cannula should have been changed. She stated Resident 18 was using the wheelchair located at the foot of the bed.…
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.
- Potential for harm · Dcited before2024-05-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 respiratory care and treatment in accordance with the facilities policy and procedures for two of five residents (Resident 1 and Resident 4) reviewed for oxygen treatment. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the residents ' health condition. Findings: On May 22, 2024, at 7:40 am, an unannounced abbreviated survey was conducted for the investigation of one complaint. A review of Resident 1 ' s History and Physical, dated May 25, 2022, indicated Resident 1 was admitted with a medical history which included chronic obstructive pulmonary disease (COPD, a lung disease causing restricted airflow or breathing problems), anxiety disorder (a disorder caused by excessive anxiety), and paranoid schizophrenia (a serious mental disorder that affects how people interpret reality). A review of Resident 1 ' s Physician ' s Orders, dated January 7, 2024, indicated May use Continuous oxygen @ (at) 2-3 L/min (liters per minute) via nasal cannula 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.
- Potential for harm · D2024-04-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, document review, and record review, the facility failed to ensure they did not place a fitted sheet on the low air loss mattress for 1 (Resident #42) of 1 sampled resident reviewed for pressure ulcer/injury. Findings included: A review of Resident #42's admission Record revealed the facility admitted the resident on 04/08/2020. Per the admission Record, the resident had diagnoses to include pressure-induced deep tissue damage of the left heel and pressure ulcer of the right heel, left heel, right ankle, and left ankle. A record review of Resident #42's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2024, revealed the resident had a Staff Assessment for Mental Status (SAMS) that indicated the resident had severely impaired cognitive skills for daily decision making. The MDS revealed the resident was at risk for pressure ulcer development and had four Stage I pressure ulcers and three unstageable pressure ulcers. A record review of Resident #42's care plan, revised on 10/16/2023, revealed the resident was at risk…
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.
- Potential for harm · Dcited before2024-04-04 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 interviews, record review, document reviews, and facility policy reviews, the facility failed to conduct outbreak testing as directed by the Centers for Disease Control and Prevention when 1 (Resident #119) of 15 sampled residents tested positive for COVID-19. Findings included: A review of the facility policy titled, Infection Prevention and Control Program, revised in June 2021, revealed It is the policy of the facility to establish and maintain and Infection Prevention and Control Program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. A review of the undated facility policy titled, Resident COVID Testing, revealed It is the policy of this facility to provide testing for the Covid-19 virus to our residents as directed by the Centers for Disease Control and the California Department of Public Health. A review of the undated facility policy titled, Employee Covid Testing, revealed It is the policy 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.
Show the remaining 7 citations
- Potential for harm · Fcited before2021-05-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. Several various size of metal sheet pans were stacked and stored wet; and 2. The ice machine was not cleaned and sanitized properly per manufacturer's guidance. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food in the facility. The facility census was 58. Findings: 1. During the initial tour in the kitchen, an observation and concurrent interview with the Dietary Services Supervisor (DSS) on May 17, 2021, at 9:10 a.m. was conducted. Two of two-third (2/3) size metal pans, two of one-quarter (1/4) size metal pans, four of full sheet metal pans were observed stacked wet and stored in the clean storage area. The DSS confirmed the mental pans were wet and stacked on top of each other. She stated that all dishes, pots, and pans should be air-dried and completely dried before stored away in the storage area. During an interview 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.
- Potential for harm · Ecited before2021-05-20 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 expired medications were removed from storage and not readily available for use, when: 1. One unopened bottle of milk of magnesia (MOM - medication to treat constipation) expired on April 2021, and one unopened bottle of an iron supplement syrup (medication to treat low iron) expired on February 2021; and 2. One open bottle of multivitamins expired on February 2021, and the multivitamins from the expired bottle were administered to Residents 1, 9, 475, 476, and 477. These failures increased the possibility for the residents to receive expired medications with decreased efficacy, and for Residents 1, 9, 475, 476, and 477 to receive medications unsafely. Findings: 1. During the medication storage inspection conducted with Licensed Vocational Nurse (LVN) 1 on May 19, 2021, beginning at 11:46 a.m., at the Station 1 medication cabinet, the following medications were found readily available for use: - One unopened bottle of MOM with an expiration date of April 2021; and - One unopened bottle of iron…
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.
- Potential for harm · E2021-05-20 · tag F0802 — failed to prepare enough nourishing food — patternProvide 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 interview and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when one [NAME] and one Dietary Aide (DA) were unable to demonstrate and verbalize the process of manual dishwashing by using a two-compartment sink. This failure had the potential to place 51 out of 58 highly susceptible residents who received food from the kitchen at risk for food-borne illness. Findings: During an interview on May 17, 2021, at 9:30 a.m., the DA verbalized and demonstrated the process of manual dishwashing with the two-compartment sink. The DA stated usually they used the two-compartment sink for wash and rinse pots and pans only and then would use the dishwashing machine for sanitizing process. The DA stated she was not sure the wash and rinse water temperature for manual dishwashing. She also stated she could not completely demonstrate and verbalized the whole process of manual dishwashing. During an interview on May 17, 2021, at 9:32 a.m., the [NAME] verbalized the process…
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.
- Potential for harm · E2021-05-20 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that the menu was being following for the therapeutic diet for lunch on May 18, 2021 when: 1. Two residents (Resident 76 and 564) on regular puree (regular diet modifies in texture of a smooth and moist consistency and able to hold its shape. Foods usually in soft and smooth state such as pudding or mashed potatoes) diet did not receive sauce on the puree chicken as indicated on the menu; 2. Two residents (Resident 475 and 469) on regular CCHO (consistent carbohydrate) diet (a diet used in the treatment for diabetes) did not receive diet gelatin dessert as indicated on the menu; and 3. One resident (Resident 53) on CCHO Large portion received extra one and half ounces of regular barbeque (BBQ) chicken. These failures had the potential to result in compromising the medical and nutrition status of those five residents. Findings: 1. During an observation of lunch meal service on May 18, 2021, beginning at 12:00 p.m., it was noted Resident 76 and 564 were on regular puree diet did not receive sauce on 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.
- Potential for harm · D2021-05-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 ensure two of 21 residents reviewed for care and treatment (Residents 4 and 470) maintained their highest practicable physical well-being when: 1. Resident 4's skin injuries on his face and chin areas were not identified, assessed, and referred to the physician. This failure had the potential to delay care and treatment for Resident 4 which could result in skin infections and worsening of the skin injuries. 2. For Resident 470, the facility did not identify and assess a dark bluish discoloration on the left neck and a yellow-greenish fading discoloration on the right jaw timely. This failure had the potential for Resident 470 to not receive care and treatment for the facial discolorations and a delay in an investigation to determine the cause of the discoloration. Findings: 1. On May 17, 2021, at 3:18 p.m., Resident 4 was observed lying in bed, awake, and able to respond to simple questions. Four dry and dark brown scabs were observed 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.
- Potential for harm · Dcited before2021-05-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed for one of one resident reviewed for oxygen therapy (Resident 50), to ensure the oxygen nasal cannula tubing (a two-pronged tubing connected to the nose) was labeled indicating the date the nasal cannula tubing was changed. This failure had the potential to result in the nasal cannula tubing to not be changed timely, which could allow infectious organisms to grow causing an infection to Resident 50. Findings: On May 18, 2021, at 11:32 a.m., Resident 50 was observed inside her room, lying in bed, asleep, with a nasal cannula in place, receiving oxygen at 2 LPM (liters per minute- a unit of measurement). The nasal cannula tubing did not have a label indicating the date when the nasal cannula tubing was changed. On May 18, 2021, at 11:35 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Resident 50's oxygen nasal cannula tubing did not have a label indicating the date when the nasal cannula tubing was changed. LVN 1 stated the licensed nurse on Sunday should have changed the nasal cannula tubing…
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.
- Potential for harm · Dcited before2021-05-20 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 implement infection control precautions to prevent cross-contamination (transfer of bacteria or other contaminants from one surface to another) when: 1. One facility staff was observed wearing artificial fingernails while assisting in feeding Resident 31 ; and 2. One facility staff did not perform hand hygiene and did not disinfect the blood pressure cuff in between uses for Residents 29 and 39. These failures had the potential to increase the risk of cross-contamination which could result in the development and transmission of infection to a vulnerable population of 58 residents in the facility. Findings: 1. On April 17, 2021, at 12:25 p.m., during dining observation in the main dining room, Certified Nursing Assistant (CNA) 3 was observed wearing artificial fingernails while assisting in feeding Resident 31. On April 17, 2021, at 12:28 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated CNA 3 was wearing…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — 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.
About 90% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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
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
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.
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 555884. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-20, 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.