Del Mar Convalescent Hospital
3136 North Del Mar Avenue, Rosemead, CA 91770 · For profit - Corporation · 59 certified beds · (626) 288-8353 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
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (22% vs 45% nationally) — better care continuity
- 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) | 4 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 | 1.7% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.3% | 4.0% | 5.4% | better |
| 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 | 0.0% | 7.3% | 6.5% | check this* — see note marked star below the table |
| 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 whose ability to walk worsened | 1.3% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 0.0% | 13.7% | 18.9% | check this* — see note marked star below the table |
| Long-stay residents given the seasonal flu vaccine | 98.1% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.4% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 0.6% | 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 | 3.4% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.3% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.1% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 3.2% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.31 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.61 | 1.57 | 1.80 | 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.
§ 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.
39.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 138 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 85.7% 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 105 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 0.65 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 34% 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 | 39.5%CMS range 27.8–47.5 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 6.6–15.2 | 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 | 85.7% | 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 | 81.0% | 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 | 68.6% | 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 | 1.3% | 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 | 9.0%CMS range 5.6–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.76 | 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 59 beds and averages 56.4 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 4.12 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.60 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.89 hrs/resident/day on weekends vs 4.21 on weekdays — 8% thinner on weekends. RN hours go from 0.75 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 22% 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.
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 · E2025-12-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1.Ensure that the physician's order for docusate sodium included the prescribed dosage and that nursing staff clarified the missing dosage prior to administration. As a result, Resident 17 received docusate sodium without a verified dosage from 12/10/2025 to 12/16/2025. This deficient practice had the potential to cause medication errors, including constipation if underdosed or diarrhea if overdosed. 2. Ensure the accuracy of the Antibiotic and Controlled Drug Record Count log for Resident 33, who was receiving Cephalexin (Keflex, an antibiotic used to treat bacterial infections in various parts of the body). 3. Ensure the Controlled Substances Shift Count log was completed and signed for 12/17/25. These deficient practices related to the facility's controlled drug records resulted in inaccurate shift count documentation and created a potential risk for medication diversio Findings: 1.During a review of Resident 17's admission 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 · E2025-12-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medication label for one of one resident (Resident 3) had an expiration/use by date. This deficient practice had the potential for Resident 3 to be administered expired medication. 1. During a review of Resident 3's admission Record (AR), the AR indicated an admission on [DATE] with hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (brain tissue death) affecting left non-dominant side, neoplasm (abnormal mass of tissue from uncontrolled cell growth) of unspecified behavior of brain, and hypertensive heart disease (problems with the heart that can develop if one has high blood pressure) with heart failure. During a review of Resident 3's History and Physical assessment dated [DATE], the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Order Summary Report, the reported indicated a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-17 · 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 properly store foods as evidenced by One open bag of dice broccoli in a freezer was not labeled and dated Two open cartons of milk in a refrigerator were not labeled and dated These deficient practices had the potential to result in residents being exposed to food borne illnesses (illnesses when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and a widespread infection in the facility. During a concurrent observation and interview on 12/15/2025 at 8:50 AM, one open bag of diced broccoli did not have a label with date in the facility kitchen freezer. The Dietary Supervisor (DS) stated the dietary staff opened and used the diced broccoli, but it was not labeled and dated on the bag. During a concurrent observation and interview on 12/15/2025 at 8:51 AM, two open cartons of milk did not have a label with date in the facility kitchen refrigerator. The DS stated the dietary staff open and used these two cartons of milk, but there was no label or dated on the cartons.…
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 · E2025-12-17 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain documentation related to current Coronavirus 2019 (COVID-19, infectious respiratory disease easily spread from person to person) vaccination status for staff. This deficient practice had the potential to result in the facility's staff and residents contracting, transmitting, and experiencing complications related to COVID-19 such as difficulty breathing, persistent pain or pressure in the chest, or diarrhea. During a concurrent interview and record review of staff vaccination logs with the Director Staff Development (DSD) on 12/17/2025 at 11:30 PM, the DSD stated the only COVID-19 Vaccination log for the staff was from 2022. The DSD stated the last COVID-19 outbreak at the facility was in 10/2025 and he could not find an updated log of staff who consented to receive, or had been administered, the COVID-19 vaccine for 2025 - 2026 from the Infection Prevention Nurse (IPN). During the same interview on 12/17/2025 at 11:55 AM, the DSD stated the importance of maintaining an updated list of staff vaccinations was 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 · D2025-12-17 · 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 promote dignity and respect for one of one sampled resident (Resident 5) when certified nurse assistant (CNA) 3 was observed standing over Resident 5 and assisting Resident 5 to eat. This deficient practice had the potential to cause a decline in the resident's individuality, self-esteem, and self-worth. A review of Resident 5's admission Record (AR) indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (long-term condition when the kidneys are damaged and lose the ability to filter waste and fluid out of the blood), Alzheimer's Disease (type of dementia [loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life] that affects memory, thinking and behavior), and dementia. A review of Resident 5's Minimum Data Set (MDS, an assessment and screen tool) dated 11/17/2025, indicated the resident had moderately impaired cognitive skills for…
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 · D2025-12-17 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the Minimum Data Set (MDS, a federal mandated resident assessment tool) assessment was accurate for one of five sampled residents (Resident 43). Resident 43's MDS did not reflect Resident 43's current diagnosis of Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities). This deficient practice resulted in lack of monitoring Resident 43's signs and symptoms of depression. During a record review of the admission record (AR), the AR indicated that Resident 43 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included Neuropathy (damage to the nerves outside your brain and spinal cord (peripheral nerves) that disrupts signals to your body, causing symptoms like numbness, tingling, weakness, and pain), Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities). During a review of Resident…
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 · D2025-12-17 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that two of two sampled residents (Resident 8 and Resident 43) reviewed for comprehensive care plans had their care plan interventions implemented by failing to: Implement Resident 8's antiplatelet care plan interventions for monitoring for bleeding or bruising. 2. Implement Resident 43's mood problem care plan interventions for monitoring feeling of sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits; change in sleep patterns' dimmish ability to concentrate; change in psychomotor skills. These deficient practices had the potential to negatively affect the resident's well-being and delay delivery of care and services to Residents 8 and 43. a. During a review of Resident's 8 admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction (a stroke, loss of blood flow to a part of the brain),…
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 · D2025-12-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 a nutritional assessment was completed one of one sampled resident (Resident 4) when a significant weight loss (losing more than 5% of your body weight [around 10 pounds for many adults]within 6 to 12 months without trying) and a change in diet was identified. This deficient practice had the potential to result in Resident 4 to not receive the appropriate diet and nutritional needs required to address Resident 4's weight loss. A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (brain tissue death) affecting right dominant side, dysphagia (difficulty swallowing), and aphasia (communication disorder from brain damage that impairs speaking, understanding, reading, or writing). A review of Resident 4's History and Physical Assessment…
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 · D2025-12-17 · 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 observation, interview and record review the facility failed to ensure that one of five sampled residents (Resident 8) was free from unnecessary drugs by failing to adequately monitor Resident 8's continuous need of Plavix (clopidogrel) (a medication used to treat and prevent blood clots) a medication that may increase the risk of bleeding. This deficient practice placed Resident 8 at risk of uncontrolled bleeding. During a review of Resident's 8 admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction (a stroke, loss of blood flow to a part of the brain), Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Pancytopenia (a blood condition where there's a significant drop in all three blood cell types: red blood cells, white blood cells, and platelets, often due to issues with bone marrow function, causing symptoms like fatigue, frequent infections, and easy…
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 before2024-11-10 · 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 follow their policy and procedures to prevent food contamination and the spread of foodborne illness for one of one kitchen in the facility, when multiple food items in the kitchen ' s refrigerator were not labeled with the date and time the food was opened or prepared. This deficient practice had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead hospitalization. Findings: 1. During an observation on 11/08/2024 at 4:13 PM in the facility ' s kitchen, the following food items inside the kitchen ' s refrigerator were observed unlabeled: 4 Cups of Fruit Mix 1 Bowl of Fruit Mix During a concurrent observation and interview on 11/08/2024 at 4:16 PM in the facility ' s kitchen with Assistant Kitchen Manager (AK), the AK stated that prepared and opened food items must be labeled with the date the item was opened and when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · Ecited before2024-11-10 · tag F0911 — patternEnsure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident bedrooms accommodate no more than four residents for seven (7) of eighteen (18) rooms (Rooms 16, 19, 20, 21, 22, 25, and 26) and did not have more than four residents in one shared room. This deficient practice had the potential to limit care and services, and the ability to move easily in the room for residents and staff. Findings: During the facility ' s Recertification Survey Entrance Conference, on 11/8/2024 at 5 PM, in the presence of the Administrator (ADM), the ADM stated the facility had rooms with variances and will continue to apply for the Room Waiver. During a review of the room waiver letter submitted by the ADM on 11/8/2024, the letter indicated Rooms 16, 19, 20, 21, 22, 25, and 26, had adequate space for nursing care and multiple beds per room would not adversely affect the health and safety of the residents. During a review of the Client Accommodation Analysis form submitted by the facility 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 before2024-11-10 · 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 two of three sampled residents (Resident 21 and Resident 23) by ensuring the residents ' call lights (a device used to alert staff to the resident ' s room) were placed within the resident ' s reach, in accordance with the facility ' s policy and procedure [P&P] titled Call Lights: Accessibility and Timely Response. This deficient practice had the potential for the residents not to receive care and services that could result in accidents and falls. Findings: 1. During a review of Resident 21 ' s admission Record, the admission Record indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (total or partial paralysis of one side of the body), hemiparesis (weakness or an inability to move on one side of the body), and paralytic syndrome (a condition that causes weakness, muscle wasting, and loss of reflexes in the body) During a review of Resident 21 ' s…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-10 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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: 1. Resident 37 ' s Physician Orders for Life Sustaining Treatment (POLST) and Advance Directive Acknowledgment Form reflected Resident 37 ' s Advance Directive. 2. Resident 30 ' s POLST reflected Resident 30 ' s Advance Directive wishes and failed to provide Resident 30 with an Advance Directive Acknowledgment form. This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident ' s wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: 1. During a review of Resident 37 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated a readmission to the facility on 9/8/2024 with diagnoses that included of spinal stenosis (spaces inside the bones of the spine get too small), encounter of orthopedic (branch of surgery concerned with conditions involving 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 · D2024-11-10 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review for two of three sampled residents (Resident 24 and 54) the facility failed to ensure: 1. Ensure Resident 24 ' s family representative received a written notification of proposed transfer and/or discharge notification upon resident ' s transfer to the General Acute Care Hospital (GACH) in accordance with the facility ' s policy and procedure and have documented evidence Resident 30 ' s notice was sent to the Ombudsman 2. For Resident 54, the facility did not have documented evidence that notice of transfer was sent to the Ombudsman. This failure violated the resident ' s and resident representative ' s rights to make informed decisions and receive transfer/discharge information of their rights to appeal the transfer/discharge. Findings: 1.A review of Resident 24 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was originally admitted to the facility on [DATE] and then readmitted 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 before2024-11-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents assessed at risk for falls received care and services, in accordance with their individualized level of risk to minimize the likelihood of falls, as indicated with the facility ' s policy and procedure [P&P] titled Fall prevention program for two of three sampled residents (Resident 6 and 30) by failing to: 1. Ensure the facility staff place the motion alarm on the bed when transferring Resident 6 from the wheelchair to the bed as indicated in Resident 6 ' s care plan for Falls. 2. Ensure to monitor the function and placement of Resident 30 ' s motion alarm when in bed and wheelchair. On 11/08/2024, Resident 30 ' s motion alarm was observed disconnected while in bed. These failures had the potential to result in multiple falls with injuries for both Resident 6 and 30 who were assessed as high risk for falls. Findings: 1. During a review of Resident 6 ' s Face Sheet (front page of the chart that contains a summary of basic…
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 before2024-11-10 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 ensure one of three residents (Resident 44) is free from significant medication errors when Resident' 44 ' s medication Droxidopa Oral Capsule (medication used to treat symptoms dizziness, lightheadedness or fainting sensation) route of administration did not match Physicians order on Resident 44 ' s Medication Administration Record (MAR) with route of administration (this means by which medication is introduced in the body such as orally, injection or topical application). This deficient practice had the potential to result in Resident 44 to receive medications through the wrong route. Findings: A review of Resident 44 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was admitted to the facility on [DATE], with diagnoses that included Parkinson ' s ( a progressive brain disorder that causes nerve cells in the brain to deteriorate) disease without dyskinesia (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-12 · 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 reasonably accommodate the resident's needs as indicated in the facility's policy and procedure titled, Call Lights: Accessibility and Timely Response for 1 of two residents (Resident 104) who was observed with call lights (device used by a resident to signal his or her need for assistance from professional staff) not within the resident's reach. This deficient practice had the potential to in Resident 104 receive delayed care or not receive services and emergency care when needed. Findings: A review of Resident 104's admission Record indicated Resident 104 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnosis that included dysphagia (difficulty swallowing foods or liquids) and type 2 diabetes mellitus (a disease in which your blood glucose, or high blood sugar levels). A review of Resident 104's History and Physical (H&P), dated 10/27/2023 indicated, Resident 104 had the capacity to understand and make…
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 · D2023-11-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed maintain a homelike environment by ensuring the facility's wall clocks in the resident's bedroom were set in the current time for 2 of two sampled residents (Resident 1 and 105). This deficient practice had the potential for Resident 1 and105 to get disoriented with time, which could affect the resident's participation with daily activities and over all wellbeing. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included paraplegia (paralysis or unable to move the lower part of the body), Type 2 diabetes mellitus (a disease in which your blood glucose, or high blood sugar levels). A review of Resident 1's History and Physical, dated 7/26/2022, indicated the resident had the capacity to understand or make decisions. 2. A review of Resident 105's admission Record indicated Resident 105 was initially admitted to the facility…
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 · D2023-11-12 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of resident's admission to the facility for one of 3 sampled residents (Resident 105) with a diagnosis of Type 2 Diabetes Mellitus (DM-an adult-onset disease in which the blood glucose or sugar levels are too high). This deficient practice had the potential for Resident 105 not to receive the appropriate interventions and treatments for DM and lead to complications such as hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar). Findings: A review of Resident 105's admission Record indicated Resident 105 was initially admitted to the facility on [DATE] with a diagnosis that included Type 2 DM. Unspecified Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life.). A review of Resident 105's History and Physical, dated 11/04/23, indicated the resident did not have capacity to understand or make decisions. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 33) was assisted by two people during transfer from wheelchair to bed, and when using a Hoyer Lift (mechanical lift device with sling used to transfer residents between the bed and the chair or other location using electrical or hydraulic power). This deficient practice placed Resident 33 at risk for falls or accidents during transfers when using the Hoyer lift that could lead to injuries including possible fractures and a decline in the resident's wellbeing. Findings: During a review of Resident 33's admission Record indicated the facility admitted Resident 33 on 11/19/2022 with diagnoses that included, osteoporosis (a condition in which bones become weak and brittle) and contracture (a condition of shortening of muscle, tendons or other tissue leading to deformity, rigidity of the joints and lead to pain with limited or no joint movement). During a review of Resident 33's History and Physical, dated 6/15/2023, indicated Resident 33 does not have the capacity 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 before2023-11-12 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 ensure one of four residents (Resident 3) was free from significant medication errors. Resident's 3's heart rate was not assessed before administering Metoprolol Tartrate (a medication to treat high blood pressure and heart failure) based on physician's order to hold if Systolic Blood Pressure (SBP, measures the pressure of your blood in your arteries [tube like structure responsible for transporting blood]) less than (<) 110 milliliters per mercury (mmHg, unit of measurement) or heart rate (HR) < 60 beats per minute (bpm, unit of measurement). This deficient practice place Resident 3 at risk to experience adverse reaction (undesired effect) of Metoprolol that included dangerously low blood pressure and heart rate that could lead to death. Findings: A review of Resident 3's admission Record indicated Resident 3 was initially admitted to the facility on [DATE] with a diagnosis that included, hemiplegia (muscle weakness or partial paralysis…
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 before2023-11-12 · 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 properly store foods in the refrigerator. 1. 15 Cups of poured milk were not labeled or dated. 2. 6 Prepared sliced peaches were not labeled or dated. 3. A cracked egg was observed saturating the egg crate. These deficient practices had the potential to result in residents being exposed to food borne illnesses. Findings: During an observation of the kitchen during the initial kitchen tour on 11/10/2023 at 9:36 AM with the Dietary Supervisor (DS), refrigerator 1 was observed to have prepared milk in cups, and prepared sliced peaches without labels or dates. DS stated the cups with milk and cups with sliced peaches should have been labeled with what the contents of what the food was, and the date the food was prepared. The DS stated dating and labeling food was important to ensure food were not expired, and to prevent residents from becoming sick. During an observation in the kitchen, during the initial kitchen tour on 11/10/2023 at 9:45 AM with the DS, refrigerator 2 was observed with one (1) cracked egg in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-12 · tag F0847 — isolatedInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure one of four sampled Residents (Resident 51) and the resident's responsible party (RP) were informed and understood the concept of the proposed arbitration (solving disputes with a neutral third party instead of the court) and the Binding Arbitration Agreement (BAA, a binding agreement by the parties to submit to arbitration all or certain disputes between them in respect of a defined legal relationship, whether contractual or not) before having the resident/RP enter into a binding arbitration agreement. The deficient practice had the potential resulted in Resident 51 unknowingly giving up their right to resolve any disputes with the facility through a court of law before a jury. Findings: During a review of Resident 51's admission Record indicated the facility admitted Resident 51 on 10/14/2023 with diagnoses that included hemiplegia (paralysis of one side of the body) and diabetes mellitus (a diseases that affect how the body uses blood sugar and results in high blood sugar). During a review of Resident 51 Minimum…
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 · D2023-11-12 · 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 label the nasal cannula (NC-a device used to deliver supplemental oxygen to people) tubing with the date when it was first used for one of three sampled residents (Resident 204). This failure had the potential for Resident 204 to use contaminated or soiled NC tubing and result in the infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and a widespread infection in the facility. Findings: During a review of Resident 204's admission Record indicated the facility admitted Resident 204 on 11/6/2023 with diagnoses that include dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally) and spinal stenosis (narrowing in the spine which puts pressure on the nerves and spinal cord, causing pain, numbness, and muscle weakness). During a review of Resident 204's History and Physical (H&P), dated 11/7/2023, indicated Resident 204 had the capacity to understand and make decisions. During A review…
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 before2025-12-17 · tag F0911 — patternEnsure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
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 resident bedrooms accommodate no more than four residents for seven (7) of eighteen (18) rooms (Rooms 16, 19, 20, 21, 22, 25, and 26) did not have more than four residents in one shared room. This deficient practice had the potential to limit care and services, and the ability to move easily in the room for residents and staff. Findings: During an interview on 12/15/2025 at 2:09 PM, Administrator (ADM) stated the facility had rooms with variances and will continue to apply for the Room Waiver. During a review of the room waiver letter submitted by the ADM on 12/15/2025, indicated rooms 16, 19, 20, 21, 22, 25, and 26, had adequate space for nursing care and multiple beds per room would not adversely affect the health and safety of the residents. During a review of the Client Accommodation Analysis form submitted by the facility on 12/15/2025 indicated the following rooms had more than four beds: room [ROOM NUMBER] with 5 beds, room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2023-11-12 · tag F0911 — patternEnsure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
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 resident bedrooms accommodate no more than four residents for five of 18 rooms (Rooms 16, 19, 22, 25 and 26) did not have more than four residents in one shared room. This deficient practice had the potential to limit care and services, and the ability to move easily in the room for residents and facility staff. Findings: On 11/10/23 at 9:00 AM, during the facility's Recertification Survey Entrance Conference, in the presence of the Social Service Supervisor (SSS) stated the facility had rooms with variances and will continue to apply for the Room Waiver. A review of the Client Accommodation Analysis form submitted by the facility on 11/10/23 indicated the following rooms had more than four beds: room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds, room [ROOM NUMBER] with 5 beds. On 11/10/23 to 11/12/23, during the recertification survey, the following were…
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 DAVID JOHNSON — 48 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 | 3.2 | +1.8 vs chain |
| Health inspection | 4 of 5 | 2.7 | +1.3 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 47 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 47; lowest-rated first.
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 |
|---|---|---|---|---|
| GIBRALTAR CONVALESCENT HOSPITAL INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 04/01/1977 |
| DEHGHANMANESH, ADRIAN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2021 |
| JOHNSON, FRANK | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/12/1989 |
| KOCHEK, JOSHUA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2022 |
| OXFORD, MICHEAL | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/03/2022 |
| FARRALES, MARY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| CLAYTON, CRAIG | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2022 |
| TRAN, DAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2024 |
| DMPA PROPCO, LLC | Organization | ADP OF THE SNF | — | since 01/30/2025 |
| SUN MAR MANAGEMENT SERVICES | Organization | ADP OF THE SNF | — | since 10/12/1989 |
| CAO, JIE | Individual | ADP OF THE SNF | — | since 01/02/2017 |
CMS files one row per role, so the 29 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $795K 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 555081. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.