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University Post-Acute Rehab

2120 Stockton Boulevard, Sacramento, CA 95817 · For profit - Corporation · 59 certified beds · (916) 452-6631 Medicare & Medicaid certified

Call the home — (916) 452-6631 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2024
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2221 Stockton Blvd · (916) 734-2680 · Call to confirm hours
Pharmacy
2221 Stockton Blvd · (916) 734-3244 · Call to confirm hours
Grocery
3100 Broadway · (916) 455-9637 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 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 improved from 4 to 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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.8%10.2%15.4%better
Long-stay residents who lose too much weight1.0%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.9%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened20.1%9.8%16.1%worse
Long-stay residents on antianxiety or hypnotic medication5.0%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers2.9%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control25.2%10.2%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table1.4%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine95.0%93.2%79.4%better
Short-stay residents rehospitalized after admission16.2%23.0%22.6%better
Short-stay residents with an outpatient ER visit9.8%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days2.082.251.67worse
Long-stay outpatient ER visits per 1,000 resident days0.461.571.80better

* 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.

59.6% 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 300 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.6%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
78.5%U.S. median 56.6%
Met the expected recovery
0.78U.S. median 0.31
Therapy hours / resident / day
0.33hours / resident / day
Physical therapy
0.37hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 78.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 149 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 0.78 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF59.6%CMS range 54.7–64.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.5–12.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge78.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge69.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge76.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.7%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge99.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.6%CMS range 4.3–10.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.221.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.29
RN hours/ resident / day
0.72
LPN hours/ resident / day
2.54
Aide hours/ resident / day
4.55
Total nurse hours/ resident / day
1.11
RN hoursweekends
31.9%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 59 beds and averages 54.8 residents a day — about 93% occupied, or roughly 4 beds typically open. It runs fairly full. 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 4.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.29 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 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 4.22 hrs/resident/day on weekends vs 4.68 on weekdays — 10% thinner on weekends. RN hours go from 1.36 to 1.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% 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

8
deficiencies at the latest standard inspection (2025-05-22)
5
at the previous standard inspection (2024-06-06)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

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 · Ecited before2025-05-22 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure care plans (a summary of a person's health conditions, specific care needs, and current treatments) were developed for three of 19 sampled residents (Resident 14, Resident 17, and Resident 27) when: 1. Resident 14 had no anticoagulant (a medicine that help prevent blood clots) monitoring care plan; 2. Resident 17 had no bed alarm and wheelchair alarm (pads that contains sensors that trigger an alarm when they detect a change in pressure) monitoring care plan; and, 3. Resident 27 had no bed alarm monitoring care plan. These failures had the potential to result in inaccurate and inadequate care being provided to Resident 14, 17, and 27. Findings: 1. Resident 14 was admitted to the facility in late 2024 with diagnoses which included heart failure and history of blood clots. During a review of Resident 14's Order Summary Report [OSR], dated 5/21/25, the OSR indicated, Apixaban .[an anticoagulant medication used to decrease the clotting ability of blood and prevents harmful clots]. Give 1 by mouth two times daily for DVT…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-22 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% (percent, unit of measure) for two of three sampled residents (Resident 302 and Resident 40). 1. For Resident 302, a Licensed Nurse (LN) did not administer resident's lidocaine patch (medication patch used to treat pain) 5 % as it was prescribed by the doctor. 2. For Resident 40, an LN did not administer resident's finasteride (hazardous medication used to treat an enlarged prostrate) 5 mg (milligram, unit of measure) as prescribed by the doctor. These failure resulted in a medication error rate of 6.45 % with two errors occurring out of 31 opportunities during the observation of medication administration. Findings: 1. During an observation of medication administration on 5/19/25 at 8:43 a.m., LN 4 was observed to prepare and administer Resident 302's morning medications which included two lidocaine 5% patches. The two patches were applied on Resident 302's lower back. Reconciliation of the observed medication administration for Resident 302's current Physician…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-22 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were stored correctly, when: 1. The medication refrigerator temperature was out of range in the medication room which put medication requiring specific temperature at risk of degradation, 2. Resident 36's opened inhaler (used to administer medication by breathing in) in the medication cart 1 was not dated when opened, which put Resident 36 at risk of receiving ineffective expired or outdated medication, 3. An opened, undated multidose container of glucose test strip was found in medication cart 1, which had the potential risk of using expired, or inaccurate glucose test strips to monitor resident's blood glucose levels. These failures had the potential to result in ineffective medication therapy for residents receiving medications stored in the medication refrigerator, for Resident 36 and for residents using glucose test strips from the medication cart 1. Findings: 1. During a concurrent observation and interview on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-22 · tag F0806 — failed to honor food preferences — pattern
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 alternative meal options of similar protein/calorie value to the meal entrée when grilled cheese sandwich or cheese quesadilla were provided in place of the entree. This failure had the potential of leading to protein/calorie malnutrition for those choosing these alternatives for census of 50. Findings: During the initial kitchen tour on 5/19/25 at 8:15 a.m., the alternative menu was observed hanging in the kitchen over the preparation counter. This menu included the option of a grilled cheese sandwich as an alternate meal. During an observation of the lunch meal plating on 5/20/25 at 12:10 p.m., a cheese quesadilla was prepared as an alternative to the main entrée. Later two grilled cheese sandwiches were also prepared and given instead of the entree. One cheese sandwich was for a resident who requested no pork or chicken. The sandwich was made with two slices of bread and one slice of cheese. The quesadilla was made with two corn tortillas and one-fourth cup shredded cheese, the equivalent of two…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-22 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety when: 1. Sanitation was compromised by rust-colored stains under the hand wash sink, and there were unpainted patches on several walls in kitchen and dry storage, 2. Food items were found with incomplete labeling, 3. Expired foods were found in the reach-in refrigerator, 4. A wet steam table pan was found stored wet, 5. Dumpster lid was propped open on two difference occasions, and 6. Tuna salad made from room temperature tuna was not monitored and cool-down to 41 degrees F (Fahrenheit, a unit of measure). These failures had the potential to lead to the growth of microorganisms (bacteria, virus, or fungus) and foodborne illness for the 50 residents eating facility prepared meals. Findings: 1. During the initial kitchen tour on 5/19/25 at 8:15 a.m., rust-colored stains were noted under the hand washing sink and unpainted patches were seen on several walls in the kitchen and dry storage areas. During a concurrent…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-22 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow infection control policies for three sampled residents (Resident 12, Resident 24, and Resident 38) out of a census of 50 when: 1. Staff did not wear a gown when providing high contact care to one resident (Resident 12) on Enhanced Barrier Precautions (an infection control strategy used in healthcare settings to prevent the spread of multi-drug resistance organisms) nor did staff wash hands or change gloves between residents' care (Resident 12 and Resident 38); and, 2. Resident 24's oxygen tubing was not labeled with a start date. These failures had the increased potential to spread of infection for the residents in the facility. Findings: 1. Resident 38 was admitted to the facility early 2025 with diagnoses which included infection of spine hardware, respiratory failure, pneumonia, and bacterial infection resistant to common antibiotics. Resident 12 was admitted to the facility early 2025 with diagnoses which included brain dysfunction, inadequate control of blood sugars, kidney failure, thyroid…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-22 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to meet professional standards for one of 19 sampled residents (Resident 8) when Resident 8's oxygen order was not implemented according to physician orders. This failure had the potential to result in respiratory failure (low oxygen levels in the blood and difficulty breathing) for Resident 8. Findings: Resident 8 was admitted to the facility in May of 2024 with medical diagnoses of acute and chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and pneumonia. Resident 8 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 10 out of 15 which indicated Resident 8 was moderately impaired in cognitive function. Review of physician orders indicated Resident 8 had a physician order for, O2 @ 2L per minute via NC every shift for SOB (oxygen at two liters per minute…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-22 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for one of 50 residents when two controlled drug record forms (count sheet forms for medication that may be abused or cause addiction) were not accurately completed for Resident 12. This failure had the potential in diversion of the Resident's 12 controlled medications and increased risk of medication error. Findings: During an inspection of medication cart 1 on 5/19/25 at 3:33 p.m. with Licensed Nurse 2 (LN 2), two controlled drug count sheets were identified to have inaccurate counts for Resident 12's buprenorphine patch (a medication patch delivers opioid through the skin to control chronic pain) 10 mcg/hr (microgram per hour, unit of measure). During an interview on 5/19/25 at 3:33 p.m. with LN 2, LN 2 stated a buprenorphine patch was given to Resident 12 on 5/18/25 at 9 a.m.; however, it was inaccurately documented on the wrong count sheet for the wrong prescription count sheet. LN 2 acknowledged because of this error both count sheets had incorrect counts on them…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-11 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to safely administer medications according to professional standards of care for one of three sampled residents (Resident 1), when staff at day program administered Resident 1's noon medications twice. This failure increased Resident 1's potential to develop adverse effects from medications. Findings: A review of Resident 1's admission record indicated he was readmitted to the facility on [DATE] with diagnoses including epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures), parkinsonism (a clinical syndrome characterized by motor symptoms that mimic Parkinson's disease. Symptoms include involuntary shaking, muscle stiffness, slow movements, and difficulty with balance and coordination.), and gastro-esophageal reflux disease (GERD- common condition in which the stomach contents move up into the esophagus). During an interview on 3/10/25 at 12:33 p.m. with the Director of Nursing (DON), DON stated Resident 1 attended a social…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-06 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and documentation review, the facility failed to discard expired medications and medications with no expiration dates, for a census of 58 when, expired medications were mixed with non-expired medications, available for use, in the medication storage room. This failure increased the potential for medication errors and placed the residents at risk for ineffective drug therapy. Findings: During the medication storage room check on 6/4/24 starting at 3:30 p.m., with Licensed Nurse (LN 3), there were three one oz (ounce, a unit of weight, 28.4 gram) tubes of ointment, TRIPLE ANTIBIOTIC+PAIN RELIEF that were expired and mixed with other non-expired antibiotic ointments in a basket. The expiration date was 1/24. In the medication room, there were three 40 oz Calmoseptine® with Menthol 0.44%, zinc oxide 20.6% (an ointment) to treat and prevent minor skin irritations were available for use with no expiration dates. Review of the facility's April 2008 policy and procedure, Medication Storage in the Facility, stipulated, Outdated .are immediately removed from…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2024-06-06 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and documentation review, the facility failed to resolve one of 16 sampled residents (Resident 38's) grievance when the resident's co-pay for replacement of lost hearing aids was not reimbursed in a timely manner. This failure resulted in Resident 38's family member wondering if and when the co-pay was to be reimbursed by the facility. Findings: Review of Resident 38's clinical record, admission Record, indicated the resident had diagnoses that included a cognitive communication deficit. In a Resident Representative (RR) interview on 6/3/24 at 11:18 p.m. in the hallway outside Resident 38's room, the RR reported that the resident's hearing aids were lost in the facility that the resident brought with them upon admission. The RR stated, The hearing aids, charger and everything was gone. The RR stated the family reported the missing hearing aids to the facility and was told they were not able to locate them. The RR stated the family decided to replace the missing/lost hearing aids with the resident's personal insurance rather than wait for 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-06 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to meet professional standards of quality of care for one of 16 sampled residents (Resident 35) when a pain medication and a renal nutritional supplement were not administered as ordered by the physician. This failure placed Resident 35 at risk for ineffective pain control and for nutritional imbalance. Findings: Review of Resident 35's clinical record, admission Record, indicated the resident was a long-term resident in the facility with diagnoses that included end stage kidney disease (kidneys lose the ability to remove waste and balance fluids.), unspecified protein-calorie malnutrition and on hemodialysis therapy (a treatment to filter wastes and fluid from the blood using a dialysis machine, an artificial kidney). During the Medication Administration (Med Pass) Observation on 6/4/24 at 8:42 a.m., Licensed Nurse (LN 1), in the presence of LN 2, stated Resident 35 had a physician order for Novasource, a nutrient supplement but it ran out, she, therefore, could not administer it during the med pass. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-06 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide a communication board for one of 16 sampled residents (Resident 20) who had expressive aphasia (loss of ability to express speech). This failure resulted in Resident 20 being frustrated and impeded the resident's communication with others. Findings: Review of Resident 20's clinical record, admission Record, indicated the resident had diagnoses that included aphasia following cerebral infarction (stroke). In a concurrent observation and interview on 6/3/24 at 9:35 a.m., in Resident 20's room, the resident was observed lying in bed wearing headphones. Resident 20 was able to communicate with yes and no answers to questions and maintained eye contact during the interview; however, the resident was unable to say words or phrases. When asked what her first name was, the resident started to write letters with her left index finger in the air. Resident 20 scrawled something in the air, which was difficult, if not impossible, to decipher. There was no writing board, picture board, cards, pens, papers or any…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-06 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow guidelines for Enhanced Barrier Precaution (EBP, an infection control intervention to reduce transmission of multi-drug resistant organisms) that require the use of gowns and gloves during direct care activities for two of 16 sampled residents, Resident 9 and Resident 5, when: 1. Licensed Nurse 3 (LN 3) did not wear the full required Personal Protective Equipment (PPE) before entering Resident 9's room to change his wound dressing of his right foot; and 2. Certified Nursing Assistant 1(CNA 1) did not wear the full required PPE while changing Resident 5's undergarments. This deficient practice had the potential for the spread of multi-drug resistant organisms (MDRO's, bacteria that resist treatment with more than one antibiotic) among residents, staff and visitors. Findings: 1. During a review of the admission Record for Resident 9, the admission record indicated, Resident 9 was admitted to the facility on [DATE], with diagnoses…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (Resident 1) of two sampled residents was free from abuse when Resident 2 threw water at her. This failure decreased the facility's potential to protect Resident 1's right to be free from harm. Findings: During a record review of Resident 1's face sheet indicated admission to the facility in 2021 with diagnoses which included dementia (memory loss and judgment) and cognitive communication deficit. During a record review of Resident 1's physician's order (PO), dated 7/13/23, the PO indicated, Resident does not have mental capacity to understand choices and make healthcare decisions. During a record review of Resident 1's care plan (CP) titled, Altered thought process [related to] dementia, as evidenced by short term memory problem-cannot recall after 5 minutes; long term memory impairment-cannot recall long past; unable to make decisions; poor decision making; problem understanding others; and, problem making needs known, revised…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-21 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, clinical record review, and facility documents review, the facility failed to ensure one of three residents (Resident 1) was treated with dignity and respect when Restorative Nursing Aide (RNA) 1 was rough when providing care to Resident 1 and stated to Resident 1 to stop whining and stop fussing. This failure resulted in Resident 1 to have pain and not feel human and not allowed to cry. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis (degenerative disease resulting in chronic pain) of right knee, muscle weakness, and chronic obstructive pulmonary disease (COPD-lung disease that makes it difficult to breathe). During a review of Resident 1's admission Minimum Data Set (MDS-an assessment tool), dated 12/23/23, described her as having clear speech, able to make herself understood and as able to understand others. Resident 1's BIMS (a brief screening that aids in detecting cognitive impairment) score was 13 which indicated she was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-28 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, the facility failed to implement policies and procedures for ensuring the reporting of an allegation of abuse when Resident 1 complained of being inappropriately touched on her left breast by a male occupational therapist (OT 2- a health care worker who helps individuals resume daily tasks such as dressing). This failure resulted in the facility not meeting the mandated reporting requirement of an alleged abuse and prevented the facility from immediate investigation of the allegation. Findings: Resident 1 ' s Facesheet (demographic and medical information sheet) , dated 11/3/23, indicated she was admitted to the facility for aftercare following a knee surgery. A MDS (Minimum Data Set, an assessment tool) dated 11/7/23, described Resident 1 as cognitively intact (able to follow instructions and make decisions). On 11/17/23 Resident 1 informed OT 1 that a male occupational therapist (OT 2) inappropriately touched Resident 1 on her left breast. During an interview on 11/21/23 at 10:25 a.m. with Resident 1 in Resident ' s 1 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-01-13 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure infection prevention and control guidelines were maintained for a census of 41, when: 1. Several urinals for three residents were not labeled or dated; 2. Licensed Nurse (LN) did not sanitize blood pressure cuff before use, and did not wear gloves when providing care to resident; 3. Drinks were found in the laundry room; and 4. Nasal cannula was found on the floor. These failures had the potential to result in transmission of infection in a vulnerable population. Findings: 1. During an observation on 1/10/22 at 9:05 a.m., a urinal was found on top of the night stand of Resident 15. The urinal was not labeled or dated. During a concurrent observation and interview on 1/10/22 at 9:10 a.m., in Resident 15's room with the Rehab Director (RHD), the RHD confirmed the urinal was not labeled, and stated, The urinals should be labeled and dated. During an observation on 1/10/22 at 9:14 a.m., two urinals were found on top of the bedside table and one urinal on top of the night stand of Resident 5. The urinals…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-01-13 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 comprehensive assessments were performed in accordance with regulatory time frames for three of 18 sampled residents (Resident 90, Resident 141 and Resident 193), when the admission Minimum Data Set (MDS, an assessment tool) assessments were not completed. This failure had the potential to result in residents not meeting their highest practicable mental, physical and psychosocial well-being. Findings: Resident 90 was admitted to the facility in late 2021 with diagnoses which included stroke, rib fracture, anxiety, and surgical aftercare. Resident 141 was admitted to the facility in early 2022 with diagnoses which included surgical aftercare and gait abnormalities. Resident 193 was admitted to the facility in early 2022 with diagnoses which included hip fracture, heart failure and kidney failure. During a concurrent observation and interview on 1/12/22 at 2:32 p.m., with the Desk Nurse/Infection Preventionist (DN/IP), the DN/IP verified on the facility's electronic medical record system Resident 90's admission MDS…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-01-13 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a plan of care for two of 18 sampled residents (Resident 90 and Resident 23) when: 1. Communication care plan was not developed for Resident 90; and 2. Chair alarm care plan was not developed for Resident 23. These failures had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 90 was admitted in late 2021 with diagnoses which included stroke, weakness, difficulty walking and assistance with personal care. During a review of Resident 90's physician's orders (PO), dated 1/6/22, the PO indicated, [Resident 90] does have mental capacity. During an interview on 1/10/22 at 12:12 p.m., with Family Member (FM) 1, FM 1 stated, [Resident 90] cannot speak or read English and she has separation anxiety. During an interview on 1/10/22 at 2:11 p.m., with the Desk Nurse/Infection Preventionist (DN/IP), when asked what's the process 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-01-13 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to safely handle and store medications for a census of 41, when an expired IV (intravenous, administered through the vein) medication eKit (emergency kit) was found expired in the medication room, and another IV medication eKit was found not locked, outside the medication storage room. This failure had the potential to result in medications and drugs being accessed by unauthorized personnel for drug diversion. Findings: During a concurrent observation of the medication storage room and interview on [DATE] at 10:18 a.m., with the Director of Staff Development/Infection Preventionist (DSD/IP), an opened IV medication eKit was found. The eKit was labeled with a filled date of [DATE], and an expiration date of [DATE]. The DSD/IP verified and confirmed the eKit was expired, and stated, I don't know why it has not been picked up by the pharmacy. The eKit is expired and opened. During a concurrent observation and interview on [DATE] at 10:21 a.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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-01-13 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure safe and secure labeling and storage of medications and biologicals (vaccines or drugs) for a census of 41, when expired medications and expired IV (intravenous, administered through the vein) medication eKit (emergency kit) were found in the medication storage room. This failure had the potential to result in expired medications being administered and causing a negative effect on the health and well-being of the residents. Findings: During an observation of the medication storage room on 1/11/22 at 10:12 a.m., with the Director of Staff Development/Infection Preventionist (DSD/IP), two bottles of bismuth subsalicylate [medication for heartburn and indigestion] were found on a shelf, both with expiration dates of 12/21. During a concurrent observation and interview on 1/11/22, at 10:13 a.m., with the DSD/IP, the DSD/IP confirmed the two bottles of bismuth subsalicylate were expired, and stated, I don't know how that happened. It is expired . During a concurrent observation of the medication storage…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-13 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure resident needs were accommodated for two of 18 sampled residents (Resident 5 and Resident 10) when: 1. Call light was not within reach for Resident 5; and 2. A haircut was not provided for Resident 10. These failures had the potential to result in increased risks for unmet needs of the residents. Findings: 1. Resident 5 was admitted to the facility in the middle of 2006 with diagnoses which included left side paralysis and left hand contracture. During a review of Resident 5's Minimum Data Set (MDS, an assessment tool), dated 11/12/21, the MDS indicated Resident 5 had memory impairment and required one person assistance with activities of daily living (ADLs). During a review of Resident 5's nursing care plan (NCP) titled, Self-care deficit, dated 11/24/21, the NCP indicated, Manifested by inability to dress .Encourage resident to use call light. During a concurrent observation and interview on 1/10/22 at 9:02 a.m., with Resident 5, Resident 5's left hand had a splint, and the right hand was able to move…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-13 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 resident assessments were performed in accordance with regulatory time frames for two of 18 sampled residents (Resident 5 and Resident 2), when the quarterly Minimum Data Set (MDS, an assessment tool) assessments were not completed. This failure had the potential to result in resident's care needs not being met. Findings: Resident 5 was admitted to the facility in the middle of 2006 with diagnoses which included heart failure, kidney failure, left side paralysis and left hand contracture. Resident 2 was admitted to the facility in late 2021 with diagnoses which included heart failure, kidney failure and abnormal blood sugar levels. During a review of the facility's electronic medical records system, which contained the residents' MDS assessments, on 1/13/22, the medical records system revealed the quarterly MDS assessments for Resident 5 and Resident 2 were overdue and were not completed. During an interview on 1/13/22 at 8:34 a.m., with the Director of Staff Development (DSD), the DSD verified the MDSs for 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-13 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide the summary of the baseline care plan (BCP) to one of 18 sampled residents (Resident 90). This failure resulted in Resident 90 and family not having clear information and understanding of the resident's initial goals, discharge plans, medications, and treatment. Findings: Resident 90 was admitted in late 2021 with diagnoses which included stroke, weakness, difficulty walking, and assistance with personal care. During a review of Resident 90's clinical record titled, Baseline Care Plan, (BCP) dated 12/29/21, the BCP indicated, Initial goals .to be able to roll side to side, sit up and walk .provide translation board [Chinese-English] .focused on bed mobility, gait training for safety .Discharge plan to return home. During a review of Resident 90's physician's orders (PO), dated 1/6/22, the PO indicated, [Resident 90] does have mental capacity. During an interview on 1/10/22 at 12:12 p.m., with Family Member (FM) 1, FM 1 stated, Nobody has talked to me yet with regards to her plan to be discharged . I…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-13 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain a sanitary environment to help prevent the transmission of diseases and infections, when the dietary staff had hair not completely covered by a hair net. This failure had the potential to result in transmission of food borne illness. Findings: During an observation in the kitchen, on 1/13/22, at 6:35 a.m., with the Dietary Aid (DA) 1, the DA 1's hair was exposed around her cheeks and forehead, not completely covered with the hair net. During a concurrent observation and interview on 1/13/22, at 6:36 a.m., with DA 1, DA 1 stated, Yes, sorry, I'll put a new one on before we are ready to start tray line. During a concurrent observation and interview on 1/13/22, at 6:37 a.m., with the Dietary Manager (DM), the DM stated, Yes, the hair is visible around her face. It should all be in the hair net. During a review of the facility's policy and procedure (P&P) titled, Dress Code for Women and Men, dated 2018, the P&P indicated, Personal Hygiene and appropriate dress are very important part of the total…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ASPEN SKILLED HEALTHCARE — 35 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 →

RatingThis homeChain avg
Overall 5 of 53.7+1.3 vs chain
Health inspection 4 of 53.1+0.9 vs chain
Staffing 5 of 53.9+1.1 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 34 homes this chain runs (chain average 3.7★, per CMS)
1 of 5Kei-Ai Los Angeles Healthcare CenterLos Angeles, CA 2 of 5Berkley East Healthcare CenterSanta Monica, CA 2 of 5Bixby Towers Post-Acute RehabLong Beach, CA 2 of 5Ocean Pointe Healthcare CenterSanta Monica, CA 2 of 5Woodland Post-AcuteWoodland, CA 3 of 5Berkley Post-AcuteVan Nuys, CA 3 of 5Berkley West Healthcare CenterSanta Monica, CA 3 of 5Kei-Ai South Bay Healthcare CenterGardena, CA 3 of 5Lake Park Healthcare CenterOakland, CA 3 of 5Marina Pointe Healthcare & SubacuteCulver City, CA 3 of 5Mission Palms Healthcare CenterWestminster, CA 3 of 5Riverwood Health CareStockton, CA 3 of 5Sierra Vista HealthcareFresno, CA 3 of 5The Gardens Healthcare CenterNorthridge, CA 3 of 5Tracy Nursing And Rehabilitation CenterTracy, CA 4 of 5Alta Healthcare Center of CamarilloCamarillo, CA 4 of 5Country Crest Post-AcuteOroville, CA 4 of 5Lodi Nursing & RehabilitationLodi, CA 4 of 5North Park Post-AcuteTracy, CA 4 of 5San Juan Hills Healthcare CenterSan Juan Capistrano, CA 4 of 5South Marin Health & Wellness CenterGreenbrae, CA 4 of 5The Rehabilitation Center At The PalazzoPhoenix, AZ 4 of 5Villa Valencia Healthcare CenterLaguna Hills, CA 5 of 5Cottonwood Healthcare CenterWoodland, CA 5 of 5Greenridge Post AcuteEl Sobrante, CA 5 of 5Hillcrest Heights Healthcare CenterSan Diego, CA 5 of 5La Casa Via Transitional Care CenterWalnut Creek, CA 5 of 5Oakland Heights Nursing And RehabilitationOakland, CA 5 of 5Pacific Heights Transitional Care CenterSan Francisco, CA 5 of 5Petaluma Post-Acute RehabilitationPetaluma, CA 5 of 5Stonebrook Health And RehabilitationLos Gatos, CA 5 of 5The Avenues Transitional Care CenterSan Francisco, CA 5 of 5The Springs Healthcare Center At The CarlottaPalm Desert, CA 5 of 5Woodlands Healthcare CenterLos Gatos, CA

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 / managerTypeRoleShareSince
ASSB, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 01/12/2024
BRADSHAW, PETERIndividualINDIRECT OWNERSHIP INTERESTsince 01/12/2024
ELSNER, ERICIndividualINDIRECT OWNERSHIP INTERESTsince 01/12/2024
KIRKWOOD, JAREDIndividualINDIRECT OWNERSHIP INTERESTsince 01/12/2024
ORGILL, CRAIGIndividualINDIRECT OWNERSHIP INTERESTsince 01/12/2024
PARTI, RAJESHIndividualINDIRECT OWNERSHIP INTERESTsince 01/12/2024
PARTI, SHRUTYIndividualINDIRECT OWNERSHIP INTERESTsince 01/01/2023
PAXMAN, MARCUSIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/12/2024
RAWE, COLTONIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/12/2024
BATALLA, AMELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/12/2014
PANTOVICH, JEREMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/12/2014
XIONG, GLENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/12/2024
BRADSHAW, JEFFREYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 01/09/2026
ASPEN HEALTHCARE SERVICES LLCOrganizationADP OF THE SNFsince 01/12/2024
SEQUOIA HEALTHCARE GROUP LLCOrganizationADP OF THE SNFsince 01/12/2024
BRADY, VERNIndividualADP OF THE SNFsince 01/12/2024
CASE, RYANIndividualADP OF THE SNFsince 01/12/2024
JURADO, FRANKIndividualADP OF THE SNFsince 01/12/2024

CMS files one row per role, so the 27 rows in the source record cover these 18 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.

$10.9M
Net patient revenuemost recent cost report
+2.1%
Operating marginrevenue minus expenses
$655K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 47%Medicare 38%Other / private 15%

This home reported $655K 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

$621per resident / day
operating cost
$18,892per month
≈ monthly operating cost
$635per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555265. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-22, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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