Valencia Gardens Health Care Center
4301 Caroline Court, Riverside, CA 92506 · For profit - Corporation · 50 certified beds · (951) 683-7111 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- 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
- lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 5.1% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 4.0% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.3% | 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 | 0.0% | 1.6% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 2.1% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 90.5% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.6% | 4.3% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 6.0% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 77.1% | 93.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 21.2% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 6.0% | 11.2% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
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.
63.3% 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 213 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 122 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 0.49 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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 | 63.3%CMS range 57.8–70.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.3%CMS range 6.1–12.6 | 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 | 42.6% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 35.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 35.2% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not 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 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 | 6.9%CMS range 4.3–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.31 | 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
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 4.35 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.62 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 3.83 hrs/resident/day on weekends vs 4.57 on weekdays — 16% thinner on weekends. RN hours go from 0.57 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 25% 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 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.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Dcited before2026-06-24 · 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 interview and record review, the facility failed to ensure that medications were administered according to physician ordered parameters for two of three residents reviewed (Resident 2 and 8) when:1.For Resident 2, the licensed nurse administered the medication Losartan (high blood pressure medication) 25 mg (mg - unit of measurement) outside of the physician ordered parameters of hold for SBP (systolic [top number of blood pressure] blood pressure) less than 140 mmhg (mmhg - unit of measurement); and2.For Resident 8, the licensed nurse administered the medication Carvedilol (high blood pressure medication) 3.125 mg outside of the physician ordered parameters of hold for SBP less than 110 mmhg.This failure had the potential for Resident 2 and 8 to experience undesired hypotension.Findings:1.On June 24, 2026, Resident 2's medical record was reviewed.The admission record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia (loss of memory), and hypertension…
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 before2025-07-07 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. For Resident 7, Certified Nursing Assistant (CNA) 2 failed to use the disposable gown provided for Enhanced Barrier Precautions (EBP - infection prevention practices using gowns and gloves during high-contact resident care activities to reduce the spread of multidrug resistant organisms [MDRO] - a germ that is resistant to many antibiotics) when providing direct care; and 2. For Residents 397, 9, 5, and 399, Licensed Vocational Nurse (LVN) 4 and LVN 1, failed to properly clean and disinfect shared medication tray, shared glucometer (blood glucose device that measures and displays the amount of sugar in the blood), the shared stethoscope (a device used to listen to sounds within the body, primarily the heart, lungs and bowels) and the blood pressure cuff (an inflatable cuff used to measure blood pressure) according to the disposable wipe manufacturer's specified contact time (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 · Dcited before2025-07-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure one of two residents reviewed for accommodation of needs (Resident 11) was offerred access to his wheelchair for daily activities and a shower chair on shower days. This failure had the potential to result in Resident 11 feeling a loss of independence, dignity, and continued well-being. Findings: On June 30, 2025, at 2:38 p.m., a concurrent observation and interview was conducted with Resident 11. Resident 11 was observed lying in bed alert, oriented and well groomed. Resident 11 stated he has not been offered to get out of bed and into his wheelchair in a month. Resident 11 further stated he would like to take a shower but the facility Hoyer lift (a medical device used transfer individuals) shower net irritates his skin. Resident 11 stated he was recieving bed baths. A review of Resident 11's admission record indicated the resident was admitted into the facility on October 1, 2024, with diagnoses which included absence of right foot, absence of left leg below the knee, cellulitis (bacterial infection…
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 · D2025-07-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an assessment and evaluation for self-administration of medication for Orajel (a topical treatment for the mouth and gums to relieve pain) was completed, and had a physician order, for one of 55 residents reviewed (Resident 7). In addition, the facility failed to ensure the medication was stored properly and securely. This failed practice increased the potential for unsafe self-administration of medication for Resident 7, and the potential for visitors, and other residents to have access to the medication, which was stored at the bedside of Resident 7. Findings: During a concurrent observation and interview on July 1, 2025, at 12:40 p.m., with Resident 7 in her room, Resident 7 was awake, alert, and able to verbalize her needs. Resident 7 was observed sitting in bed eating her lunch. Her meal ticket indicated Fortified Diet (food with added vitamins, minerals, or other nutrients) mechanical soft texture, thin liquid consistency.…
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 before2025-07-07 · 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
Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one resident of two residents (Resident 6) when:1.The physician was not contacted when Resident 6 blood sugar was below ordered parameters.2. Resident 6 received hypertension (high blood pressure) medication when blood pressure was below physician ordered parameters. This failure had the potential for Resident 6 to have adverse effects of hypoglycemic (low blood sugar) and hypotension (low blood pressure). Findings:1. On July 1, 2025, at 1:13 p.m., a review of Resident 6's admission record indicated the resident was admitted into the facility on April 29, 2025, with the diagnoses which included osteomyelitis (bone infection), diabetes mellitus (high blood sugar), hypertension (high blood pressures).A review of Resident 6's medication administration record (MAR) for the month of June 2025, indicated the following:June 22, 2025, the 9 am dose of Losartan was administered with BP (blood pressure) indicating 108/54.June 22, 2025,…
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 · D2025-05-28 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a copy of the discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) the same time the notice of the discharge was provided to the resident or resident ' s representative for two of six sampled residents (Residents 1 and 3). This failure has the potential for the Ombudsman not be able to advocate for the residents in protecting their rights from inappropriate transfer and discharge. Findings: A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit and muscle weakness. Further review of the record indicated the resident was discharged to home on May 15, 2025. A review of Resident 1 ' s discharge notice indicated the resident was provided the discharge notice on May 7, 2025, with the discharge effective date of May 15, 2025. A review of the fax (facsimile) transmission…
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 · D2025-04-09 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the interventions provided to Resident 1 when she had a low blood sugar level of 37 (hypoglycemia), was documented in the medical record. This failure had the potential to affect Resident' 1's health and make it harder for nursing staff to communicate effectively and provide proper care. Findings: A review of Resident 1's admission record indicated she was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (high blood sugar level). A review of Resident 1's History and Physical dated December 19, 2024, indicated she had the capacity to understand and make decisions. A review of Resident 1's Medication Administration Record (MAR) for the month of January 2025 indicated she had a blood sugar level of 37 at 6:30 a.m. on January 1, 2025. A review of Resident 1's SBAR (Situation Background Assessment Recommendation- a standardized communication tool) Communication Form and progress note . written by Licensed Vocationa…
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 · E2024-06-06 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 interview and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse and addiction) for three of four random sampled residents (Residents 1, 18, and 247) when a random controlled medication audit did not reconcile. The controlled medications were signed out of the Medication Count Sheet (a controlled drug record, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. The failure resulted in inaccurate accountability of controlled medications, which had the potential for misuse or diversion. Findings: The Medication Count Sheets for controlled medications for four random residents receiving PRN (as-needed) controlled medications were requested for review during the survey and indicated the following: 1. Resident 247 had a physician's order, dated March 24, 2024, for Norco (hydrocodone-acetaminophen, a potent controlled medication for pain) 5/325 milligram (mg,…
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 · E2024-06-06 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the physician's order to hold the administration of the the medication Hydralazine Hydrochloride (medication used to control high blood pressure) for the systolic blood pressure (top number) less than 130 for one resident reviewed (Resident 35). This failure resulted in Resident 35 receiving the medication multiple times below the prescribed parameter as ordered by the physician from May 11, 2024 through June 3, 2024. Findings: On April 3, 2024, at 7:10 a.m., Resident 35 was observed awake, alert and able to verbalize her needs. Resident 35 was observed with oxygen on at two liters (a unit of measurement) of oxygen per minute through nasal cannula (a tube used to deliver oxygen through the nostrils). On April 3, 2024, a review of Resident 35's record indicated, Resident 35 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure) and Chronic Obstructive Pulmonary Disease (COPD- lung…
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 · E2024-06-06 · 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 observation, interview, and record review, the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Dietary Aide (DA) 3 did not follow the facility cleaning procedure to clean food preparation surface and stationary equipment (Cross referred F 812); 2. Two kitchen staff did not document the cooling process on June 2, 2024 for making boiled eggs (Cook 2) and on June 2, 2024, for making tuna salad (Dietary Aide 1); 3. [NAME] 3 did not know how to calibrate a thermometer; 4. [NAME] 1 did not follow the time length according to manufacturer's guidelines for dipping the test strip in the sanitizer (sanitizing solution used for sanitizing food contact surfaces); and 5. DA 2 did not follow the time length according to manufacturer's guidelines for immersing kitchenware in sanitizer solution in the sanitize sink. These failures had the potential for unsafe food practices which may lead to foodborne illness (stomach illness acquired from ingesting contaminated food), and the potential to not meet…
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 16 citations
- Potential for harm · E2024-06-06 · 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 the nutritional needs for three of eight sample residents (Residents 297, 25, and 26), was met, when the meal was not served in accordance with menu guidance for lunch when: 1. Resident 297, who was on a physician prescribed Fortified diet (diet with added extra nutrients to increase calories and/or protein density to promote improvement in residents' nutritional status), received diet Jello instead regular Jello on June 3, 2024, lunch and received 1 package of dressing instead of 2 packages of dressing on June 4, 2024, lunch; 2. Resident 25, who was on a physician prescribed Controlled Carbohydrate Diet (CCDO: a meal plan for diabetic residents), received regular dessert instead of diet dessert on June 4, 2024; and 3. Resident 26, who was on a physician prescribed large portion diet, did not received large portion on June 4, 2024. These failures had the potential to result in under or over nutrition. When a resident receives foods that are not consistent with their physician ordered diet, it may…
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 · E2024-06-06 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Food service workers did not follow the facility cleaning procedure to clean food preparation surfaces; 2. Dust found in several areas in kitchen, ice machine room and dry storage room; 3. Poor quality produce found in walk-in refrigerator; 4. Can opener and base had buildup; 5. Blender had buildup; 6. Floor in the kitchen and dry storage room found dust and food particles; 7. The hot water spout on the coffee maker had hard water buildup; 8. One food container stacked wet in dry storage room; 9. Bottom of small oven found black particles; 10. Two opened food items exposed to air in reach-in freezer; 11. A container which stored Margarine did not have an identification label and date; and 12. Microwave had buildup/splatter dried inside. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 48 out of 50 residents who…
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 before2024-06-06 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure infection control and prevention practices were observed when: 1. For Resident 147, there was no enhanced barrier precaution (EBP - an infection control method that use personal protective equipment [PPE - medical equipment for protection] to reduce the spread of infection) sign posted and there was no container found in the room to dispose the used cloth gowns and linens to care for the resident who had a urinary catheter (a flexible tube used to empty the bladder [body organ that stores urine]) in place; 2. Nursing staff failed to properly clean and disinfect a shared automatic blood pressure (BP - pressure of blood in blood vessels) cuff machine after use according to the facility's policy for Resident 101; 3. Nursing staff failed to properly clean and disinfect the resident's prefilled insulin (medication for diabetes) pen before use according to manufacturer's specifications for Residents 27 and 37; and 4. Nursing staff failed…
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 · E2024-06-06 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure equipment in the kitchen was clean and maintained in a safe operating condition when: 1. There was ice buildup in reach-in freezer; 2. Three out of three cracked white shelves in reach-in freezer; 3. The bottom shelf of the prep table corrosion; 4. Two out of two silver storage shelves found had rust in dry storage room at kitchen; 5. One blue cutting board a rough surface; and 6. The drying dome rack had cracked coating with exposed rusting metal. These failures had the potential for equipment not functioning in the way they were intended and in turn cause contamination of food which could lead to food borne illnesses for 48 out of 50 residents. Findings: 1. During a review of the U.S. Food and Drug Administration's (FDA) Food Code 2022, Annex 3: 4-501.11 Good Repair and Proper Adjustment, the Food Code indicated, .Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations 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.
- Potential for harm · E2024-06-06 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility document review, the facility failed to ensure an effective pest control program was in place for the kitchen, when a gnat was observed in a storage room on June 3, 2024, and four house flies were observed flying and landing in the kitchen on June 4, 2024. This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in the facility residents who eat food prepared in the kitchen. Findings: During an observation on June 3, 2024, at 6:44 a.m., in the kitchen dry storage room, there was a plastic bin with four brown bananas in it, with a gnat/fruit fly flying around the fruit. During an interview on June 3, 2024, at 8:04 a.m., with Dietary Services Supervisor (DSS), DSS stated the ripe bananas attract gnats and the kitchen cannot have pests because it can cause cross contamination of the foods served. During a concurrent observation and interview on June 4, 2024, at 4:16 p.m., with [NAME] 3, there were four flies seen in the kitchen, flying around 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 · D2024-06-06 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident reviewed (Resident 297) was treated with respect and dignity by failing to ensure Resident 297's indwelling urinary catheter (medical device that helps drain urine from your bladder) drainage bag (holds the urine) had a dignity bag (a bag used to cover a urinary drainage bag, so it was not visible). This deficient practice had the potential to cause Resident 297 psychosocial harm and for the resident to feel embarrassed. Findings: During a review of Resident 297's admission Record, the admission Record indicated Resident 297 was admitted to the facility on [DATE], with diagnoses of cerebral palsy (congenital disorder of movement, muscle tone, or posture), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems) and hemiplegia (partial paralysis on one side of the body). During a review of Resident 297's minimum data set (MDS - an assessment tool), dated May 22, 2024, 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 · Dcited before2024-06-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate the needs for one resident reviewed (Resident 30), when the call light button was observed not within reach. This failure had the potential for Resident 30 not to be able to call staff for assistance which could result in the resident's needs going unmet. Findings: On June 3, 2024, at 8:22 a.m., during an observation and concurrent interview with Resident 30, the resident's call light button was observed hanging on the wall at the head of the bed and secured to the wall by a clamp. Resident 30 stated he would not be able to reach the call light button secured to the wall. The call light button was not within the resident's reach. On June 3, 2024, at 8:41 a.m., during an observation and concurrent interview with Certified Nurse Assistant (CNA) 2, CNA 2 acknowledged Resident 30 was not able to reach the call light and the call light should be within reach. CNA 2 further stated the resident could not reach the call light hanging…
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 · D2024-06-06 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 resident's family member (FM) of the change in condition and transfer to the acute hospital for one of three residents reviewed for closed record (Resident 45). This failure resulted in Resident 45's FM looking for Resident 45 two days after Resident 45 had a change in condition and was transferred to the acute hospital on March 10, 2024. Findings: On June 6, 2024, Resident 45's record was reviewed. Resident 45 was admitted to the facility on [DATE], with diagnoses which included malignant neoplasm of the prostate (cancer of the prostate) and severe protein-calorie malnutrition (a condition when a person does not eat enough protein and calories). The history and physical (H&P), dated March 9, 2024, indicated Resident 45 was diagnosed a year ago but never followed up for treatment. Resident 45 was at the acute hospital for anemia (a condition in which the blood does not have healthy red blood cells and hemoglobin) that required 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.
- Potential for harm · D2024-06-06 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update and revise the resident's care plan when one resident reviewed (Resident 8) was transferred to the hospital for chest pain. This failure had the potentail to delay the necessary care and services for Resident 8 when the care plan was not updated with specific measurable goals and interventions for his chest pain when he returned to the facility. Findings: On June 3, 2024, at 10:25 a.m., Resident 8 was observed sitting in her wheelchair playing a game on the television. Resident 8 denied any discomfort. During a review of Resident 8's record, the record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included Congestive Heart Failure (CHF- heart failure), myocardial infarction (MI - a heart attack) and presence of cardiac pacemaker (a device used to control irregular heart rhythm). The SBAR Communication Form (Situation Background Assessment Recommendation - communication between health care team…
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 before2024-06-06 · 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 obtain the pacemaker (a device used to treat irregular heart beats) information and include the information in the plan of care for two of three residents reviewed (Residents 8 and 97). This failure resulted in Resident 8 and 97 not being seen and evaluated by their cardiologists (doctor specializing in the heart) and the facility staff not having information about the residents' pacemaker, which could delay the necessary care and services if the pacemaker malfunctioned. Findings: 1. On June 3, 2024, at 10:25 a.m., Resident 8 was observed sitting in her wheelchair, playing agame on the television. Resident 8 denied any discomfort. During a review of Resident 8's record, the record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included Congestive Heart Failure (CHF- heart failure), myocardial infarction (MI - a heart attack) and presence of a cardiac pacemaker. The SBAR Communication Form (Situation…
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 · D2024-06-06 · 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 in accordance with the facility's policy and procedure for one of three residents (Resident 147) reviewed for oxygen administration when Resident 147 was administered oxygen without a physician's order. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in Resident 147's health condition. Findings: On June 3, 2024, at 7:05 a.m., Resident 147 was observed in bed, in her room. Resident 147 was using oxygen at two liters (a unit of measurement) per nasal cannula (a tube used to deliver oxygen through the nose) attached to an oxygen concentrator (a machine that supplies oxygen). On June 4, 2024, at 12:22 p.m., Resident 147 was observed sitting in the wheelchair, transported by a staff back to her room. Resident 147 was using oxygen at two liters per nasal cannula attached to an oxygen tank (a portable container that supplies oxygen). Resident 147…
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 · D2024-06-06 · 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 13.89% when five medication errors occurred out of 36 opportunities during medication administration for two out of four residents (Residents 32 & 101). This failure resulted in medications not given according to physician's orders and had the potential for Resident 32 and Resident 101 to not receive the full therapeutic (relating to the healing of disease) effects of the medication. Findings: 1. During a medication pass observation on June 3, 2024, at 8:01 a.m., Licensed Vocational Nurse (LVN) 3 was observed removing an automatic blood pressure (BP-pressure of blood in blood vessels) cuff machine from inside the medication cart and then proceeded into Resident 101's room. LVN 3 applied the automatic BP cuff on Resident 101's left arm. When the machine completed measuring the resident's BP, LVN 3 stated the BP result (BP result consists of two numbers: the top number or systolic blood pressure [SBP] and the bottom number or diastolic blood pressure [DBP]) reading was 124 over 57. LVN 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.
- Potential for harm · Dcited before2023-10-19 · 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
Based on observation, interview, and record review, the facility failed to ensure COVID-19 (an infectious disease caused by SARS-CoV-2 Virus) outbreak was reported when a resident with symptom had tested positive for COVID-19 infection on September 4, 2023. The facility failure had delayed early intervention to monitor and prevent virus spread and proliferation as reporting was intended to facilitate timely intervention. Findings: On September 28, 2023, at 10:10 a.m., an unannounced visit was conducted to investigate a COVID-19 outbreak. During the visit, the receptionist (Receptionist/Payroll) was observed wearing an N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of 95% airborne particles) and had not been conducting active screening. The receptionist stated they have four (4) COVID-19 positive residents in the facility. On September 28, 2023, at 10:20 a.m., the Director of Nursing (DON) was interviewed. DON provided documented evidence they had notified the county but failed to report the outbreak to the state…
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.
- No harm found · Bcited before2025-07-07 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
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 the required bedroom space, measuring at least 80 square feet per resident, in 12 resident rooms (Rooms: 16, 17, 19, 21, 23, 24, 27, 29, 30, 32, 33, and 34). Findings: On June 30, 2025, at 2:38 p.m., a concurrent observation and interview was conducted with Resident 11 in room [ROOM NUMBER] A. Resident 11 was observed awake and oriented sitting in bed watching television. Resident 11 stated he did not feel the room size interfered with his care. On June 30, 2025, at 3:47 p.m., a concurrent observation and interview was conducted with Resident 34 in room [ROOM NUMBER] A. Resident 11 was observed in a wheelchair self-propelling himself into room [ROOM NUMBER]. Resident 34 stated he has no issues with his room size and stated the size of the room does not interfere with his care or ability to operate his wheelchair within his room. On June 30, 2025, at 3:50 p.m., a concurrent observation and interview was conducted with the family…
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.
- No harm found · Bcited before2024-06-06 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
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 the required bedroom space, measuring at least 80 square feet per resident, in 12 resident rooms (Rooms 16, 17, 19, 21, 23, 24, 27, 29, 30, 32, 33, and 34). Findings: On June 3, 2024, at 9:06 a.m., during the entrance conference, the Administrator was interviewed regarding the room sizes for resident Rooms 16, 17, 19, 21, 23, 24, 27, 29, 30, 32, 33, and 34. The Administrator agreed the rooms did not meet the space requirement of at least 80 square feet per resident in the above-mentioned resident rooms. The Administrator stated the facility had a waiver for the rooms and would be requesting for the renewal of the waiver. On June 5, 2024, at 1:54 p.m., a concurrent observation and interview was conducted with Resident 24 in room [ROOM NUMBER]. Resident 24 was observed in bed and was awake. Resident 24 stated the room size did not interfere with his care and there was enough space for him to move about in the room. During the survey…
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.
- No harm found · Bcited before2023-07-20 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
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 the required bedroom space, measuring at least 80 square feet per resident, in 12 resident rooms (Rooms: 16, 17, 19, 21, 23, 24, 27, 29, 30, 32, 33, and 34). Findings: On July 17, 2023, at 10:04 a.m., a concurrent observation and interview was conducted with Resident 22 in room [ROOM NUMBER] A. Resident 22 was observed awake and sitting in bed. Resident 22 stated she requires assistance her care. Resident 22 stated she did not feel the room size interfered with her care and there was enough space for her when sitting up in her wheelchair. On July 17, 2023, at 2:00 p.m., a concurrent observation and interview was conducted with Resident 203 in room [ROOM NUMBER] B. Resident 203 was observed sitting in her wheelchair, Resident 203 was able to move her wheelchair using her feet. Resident 203 stated the room size did not interfere with her care and there was enough space for her to move in and out of her room. On July 17 at 4:42 p.m.,…
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.
Part of a chain
This home belongs to NAHS — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.0 | +1.0 vs chain |
| Health inspection | 4 of 5 | 3.2 | +0.8 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.8 | +0.2 vs chain |
The other 11 homes this chain runs (chain average 4.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NAHS HOLDING INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 06/30/2018 |
| HUGHES, FRANKLIN | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 08/15/2023 |
| DAHL, BRENDEN | Individual | CORPORATE DIRECTOR | — | since 02/01/2023 |
| ELLIS-SHERINIAN, JAMES | Individual | CORPORATE DIRECTOR | — | since 10/01/2020 |
| JOHNSON, MARC | Individual | CORPORATE OFFICER | — | since 11/20/2022 |
| LUNDQUIST, VICTOR | Individual | CORPORATE OFFICER | — | since 03/21/2018 |
CMS files one row per role, so the 9 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $501K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 555331. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-07, 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 →
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