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Arrowhead Healthcare Center, LLC

4343 N Sierra Way, San Bernardino, CA 92407 · For profit - Limited Liability company · 58 certified beds · (909) 886-4731 Medicare & Medicaid certified

Call the home — (909) 886-4731 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 23 lower-level deficiencies on record (see below)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

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 (4/5)
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
967 Kendall Dr Ste A519 · (888) 245-1866 · Call to confirm hours
Pharmacy
4108 N Sierra Way · (909) 475-4250 · Call to confirm hours
Grocery
4090 Acre Ln · (909) 886-8007 · Call to confirm hours
Park
240 W 40th St · (909) 384-5233 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 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.

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 increased11.0%10.2%15.4%better
Long-stay residents who lose too much weight4.4%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 infection1.9%1.2%2.0%typical
Long-stay residents with depressive symptoms8.3%7.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.4%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened15.2%9.8%16.1%typical
Long-stay residents on antianxiety or hypnotic medication15.3%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers1.7%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control7.7%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 table24.6%12.0%17.1%worse
Long-stay hospitalizations per 1,000 resident days1.622.251.67typical
Long-stay outpatient ER visits per 1,000 resident days1.051.571.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.13U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

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

Staffing

0.33
RN hours/ resident / day
1.30
LPN hours/ resident / day
3.02
Aide hours/ resident / day
4.65
Total nurse hours/ resident / day
0.20
RN hoursweekends
30.6%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 58 beds and averages 53.6 residents a day — about 92% 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 4.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.02 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 3.98 hrs/resident/day on weekends vs 4.92 on weekdays — 19% thinner on weekends. RN hours go from 0.38 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% 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

9
deficiencies at the latest standard inspection (2026-04-09)
12
at the previous standard inspection (2024-12-19)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Fcited before2026-04-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe infection control practices and sanitary environment were followed when: 1.physician's orders were not followed for Resident 53 and Resident 21, when the residents' oxygen nasal cannula tubing (device used to deliver oxygen into the nose via a tube) and humidifier (bottle filled with distilled water that attaches to an oxygen concentrator or tank to add moisture to the oxygen) were found unlabeled and undated2.Three Hoyer lift (a mechanical lift) slings (strong, fabric harnesses that securely hold a person with limited mobility while a mechanical lift moves them) were observed hanging from the exterior bars outside the laundry room windows.3.The facility failed to ensure staff adhered to required infection prevention and control practices, including appropriate PPE use during high-contact care for Resident 37 on Enhanced Barrier Precautions (EBP-an infection control guideline that requires staff to wear a gown and gloves while…

    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 · Ecited before2026-04-09 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure five of five rooms (each with four resident beds per room) had the minimum required square footage for each resident. This failure had had the potential for increased risk of accidents and injuries to occur within the room as a result of limited space for wheelchair and Hoyer lift access (a mechanical device that helps move people with limited mobility), limited space to accommodate resident care activities, increased risk for falls, and a potential delay in the evacuation of residents during an emergency.Findings: During a review of the facility document titled, [name of facility] Census (a document which indicates the total number of residents within the facility and their room number) dated April 6, 2026, the document indicated there was a total of five rooms within the facility each with four beds and the ability to house 4 residents The rooms were: 102, 105, 106, 107 and 112.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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · 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 observation, interview, and record review, the facility failed to ensure dignity was maintained for one of 18 sampled residents (Resident 4) when Resident 4's urinary collection bag (bag which collect and hold urine) was found not covered with a dignity bag (a drainage bag holder used to cover and hold the catheter drainage/collection bag, so it is not visible). This failure resulted in Resident 4's urine being visible to residents, staff, and visitors, which compromised his privacy and diminished his dignity, self-worth, and sense of respect.Findings: During a review of Resident 4's admission Record, (contains demographic and medical information), indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (the final, permanent stage of chronic kidney disease where kidney function falls below 15% of normal), dependence on renal dialysis (a person's kidneys have failed [typically <15% function] and can no longer filter waste or manage fluids, making…

    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 · D2026-04-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure nursing staff followed a physician's order for hypoglycemia (low blood sugar) management for one of one sampled residents (Resident 43) reviewed for insulin (medication used to help lower blood sugar levels), when on multiple occasions, staff did not document a required repeat blood sugar check after the Resident 43's initial blood sugar was below 70 milligrams per deciliter (mg/dl).This failure resulted in Resident 43 to not receive care and monitoring of blood sugar levels as ordered by the physician and for Resident 43 to experience hypoglycemia without staff knowledge or intervention.Findings: During a review of Resident 43's admission Record (contains medical and demographic information), the admission Record, indicated Resident 43 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (condition in which the body can't regulate blood sugar levels adequately, leading to high blood sugar levels),…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 one sampled residents (Resident 6) reviewed for pressure ulcers (injury to skin and underlying tissues that develops as a result of prolonged pressure, shear, or friction) had a low air loss mattress (LAL mattress - a specialized mattress which is air filled and is designed to help prevent and treat pressure ulcers) programmed to the correct weight as ordered by the physician. This failure resulted in the low air loss mattress to not have the most therapeutic effect for the prevention and treatment of pressure ulcers and for Resident 6 to have increased risk for the development of new pressure ulcers and a delay in wound healingFindings: During a review of Resident 6's admission Record (contains medical and demographic information), the admission Record, indicated Resident 6 was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (a condition where the heart is unable to pump blood…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 their policy and procedure (P&P) for one of 18 sampled Residents (Resident 4) when: 1.Urinary collection bag was not changed every Sunday and PRN (as needed) according to physician's orders. 2. Suprapubic catheter (a tube inserted into the bladder through a small abdominal incision, rather than the urethra, to drain urine) was not flushed with 60 cc (cubic centimeter: a unit of measurement) normal saline (a solution used for flushing suprapubic catheter) according to physician's orders This failure resulted in Resident 4's urinary drainage bag not being flushed and changed for several months, placing Resident 4 at risk for developing an urinary tract infections and causing discomfort and decline in Resident 4's health and well being.Findings:1.During a review of Resident 4's admission Record (contains demographic and medical information), indicated Resident 4 was readmitted to the facility on [DATE], with diagnoses which included…

    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 · D2026-04-09 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 nursing staff were competent in the monitoring of a dialysis access sites for one of one sampled resident (Resident 31) when multiple nursing staff were documenting Resident 31 had bruit (a whooshing or humming sound heard through a stethoscope placed over a fistula [surgically created connection between and artery and a vein], and thrill (a vibration or buzzing sensation felt under the skin when you lightly place your fingertips over a fistula. A normal continuous thrill indicates a functioning, patent fistula, confirming adequate blood flow) despite Resident 31 not having a fistula and instead had a Central Venous Catheter (CVC- a long, flexible tube inserted into a large vein which provides direct access to central circulation.) In addition, no nursing staff contacted the doctor for clarification of Resident 31's physician's order. This failure resulted in inaccurate documentation and demonstrated nursing staff confusion…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 5 sampled residents (Resident 5) Metformin (a medication used for the treatment of high blood sugar) was administered as prescribed by the physician when the medication was administered without food. This failure had the potential for Resident 5 to have adverse side effects including gastrointestinal intolerance (the body's inability to properly digest or break down certain foods or substances, leading to uncomfortable digestive symptoms) and hypoglycemia (occurs when the blood sugar level drops below 70).Findings: During a review of Resident 5's admission Record (list of diagnoses and demographic information), the admission Record indicated, Resident 5 was admitted to the facility on [DATE], with the diagnoses which included Type 2 Diabetes Mellitus (a chronic condition where the body cannot effectively use insulin or produce enough of it, leading to high blood sugar levels) and Gastrostomy (a surgical procedure that…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 call light (a device that allows patients to communicate with nursing staff when they need assistance) was within residents' reach for two of six sampled residents (Resident 5 and 9) when: 1.For Resident 5, the call light was located on the floor on resident's right side of the bed and unreachable by the resident. 2.For Resident 9, the call light was wrapped around the feeding pump located on a pole away from resident's reach. This failure had the potential to placed Resident 5 and 9 at risk for their safety and well being.Findings: 1.During a review of Resident 5's admission Record ( a document that gives a summary of resident information), the admission Record indicated, Resident 5 was admitted to the facility on [DATE], with the diagnoses which included Hemiplegia (a form of paralysis that causes severe or complete loss of movement on one side of the body) and Hemiparesis (weakness on one side of the body, affecting the arm,…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-10 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was available onsite at least eight (8) hours a day, seven (7) days a week for 58 Residents from March 1, 2025, through April 10, 2025, when the facility did not have RN onsite for 3 days. This failure had a potential to negatively affect Residents overall health and safety by not having RN oversight and assessment in a universe of 58 residents. Findings: During an observation on April 10, 2025, there was no RN on duity. During an interview on April 10, 2025, at 10:47 AM, with the Administrator (Admin 1) The Admin 1 indicated that there is no RN available today as the Director of Nursing (DON 1) is absent due to Covid. She elaborated that the DON 1 is the only full-time RN on staff. Additionally, she mentioned that there is a part-time RN (RN 1) who is scheduled to work only on Mondays and Fridays from 8:00 am to 5:00 pm. The current census stands at 58 residents. She further stated according to the policy, the facility requires one RN for eight hours each day. During 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Fcited before2024-12-19 · 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 maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections, in a universe of 55 residents (Residents 1 to 55), when: 1. The facility did not conduct an annual review of its infection control program's policies and procedures (P&P) and update their program, as necessary. This failure had the potential to cause the facility to be out-of-date with current best practices and overlook potential gaps in their procedures. 2. Laundry staff (LS 1) did not follow the manufacturer's guidelines for the disinfectant used to disinfect laundry carts and dirty laundry barrels. Housekeeping staff (HS 1) did not follow the manufacturer's guidelines for the disinfectant used to disinfect resident rooms. This failure had the potential to cause the development and transmission of communicable diseases (an illness or infection that can spread from one person to another, or from a surface to a person) and infections to residents. 3. Housekeeping…

    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 · E2024-12-19 · tag F0641 — pattern
    Ensure 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 accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for four of nineteen sampled residents (Residents 25, 27, 32, and 56) when: 1) Resident 25's RAI-MDS assessment dated [DATE], incorrectly indicated Resident 25 had only minimal hearing loss, and did not have a hearing aid. 2) Resident 27's RAI-MDS assessment dated [DATE], incorrectly indicated Resident 27 was not considered Pre-admission Screening and Resident Review (PASRR) level 2 by the state. 3) Resident 32's RAI-MDS assessment dated [DATE], incorrectly indicated Resident 32 received insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood). 4) Resident 56's RAI-MDS assessment dated [DATE], incorrectly indicated Resident 56 had an indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine). These failures had 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-19 · 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, distribute, and serve food in accordance with professional standards for food service safety when: a. Walk in refrigerator and freezer temperatures were not being monitored daily. b. A kitchen staff was observed working in the kitchen without a hair net. c. Shelves in the walk-in refrigerator had black residue on them where food was stored. These failures had the potential for bacteria to growth and cause foodborne illness in a highly susceptible population of 49 residents who received food and beverages from the kitchen. Findings: a. During a concurrent observation and interview on December 16, 2024, at 9:20 AM, in the kitchen with the Dietary Supervisor (DS), the walk-in refrigerator was observed not to contain a thermometer to monitor the temperatures inside, the logs identifying temperatures were being checked daily could also not be identified. The DS stated, those items need to be available, or we would not have record of if the temperature is safe. The DS further stated, they could not…

    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 · E2024-12-19 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the kitchen was free of pests, when a cockroach was observed on the wall behind the steam table (a type of food-holding equipment designed to keep hot foods at a safe holding temperature). This failure had the potential to cause contamination of food and beverage for 49 residents who receive food and beverage from the kitchen, potentially leading to a resident infection. Findings: During a concurrent observation and interview on December 16, 2024, at 8:48 AM, in the Kitchen, with the Dietary Supervisor (DS), a cockroach was observed on the wall behind the steam table in the kitchen. DS stated, There shouldn't be any bugs or cockroaches in the kitchen. During a concurrent interview and record review on December 19, 2024, at 3:34 PM, with Dietary Supervisor, the State Operations Manual §483.90(i)(4) was reviewed. The State Operations Manual §483.90(i)(4) indicated, Maintain an effective pest control program so that the facility is free of pests and rodents. Dietary Supervisor stated, we are out of…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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

    Based on interview, and record review, the facility failed to provide evidence staff discussed with one of nineteen sampled residents (Resident 32) whether the resident had an existing advance directive (a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions) and was educated on his rights to establish a new advance directive if desired. This failure had the potential for Resident 32 to receive end of life care not in accordance with his wishes and for life sustaining measures to be rendered against what the resident wanted. Findings: During a concurrent interview, and record review, on December 19, 2024, at 11:00 AM, with the Director of Nursing (DON), the DON was asked to provide evidence regarding if Resident 32 had an advance directive in place. The DON provided a copy of Resident 32'sPhysician Orders for Life-Sustaining Treatment (POLST) (written medical orders that addresses a limited number of critical medical decisions) signed by the resident on January 10, 2020. During a record 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-19 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide two of three sampled residents (Residents 17 and 28) with beneficiary liability protection notifications (A notification letter which explain resident rights regarding financial liability and the right to appeal) when: 1) Resident 17 was not provided with estimated costs on the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN - informs the resident about potential non-coverage and the option to continue services with the resident accepting financial liability for those services). 2) Resident 28 was not provided with estimated costs on SNF ABN and the Notice of Medicare Non-Coverage (NOMNC -informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization) was not provided to the resident at least two days before the end of a Medicare covered Part A stay. This failure had the potential for Residents 17 and 28 to be uninformed regarding their specific rights and protections related to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure a resident representative was notified of transfer in writing for one of 20 sampled residents (Resident 17). This failure had the potential to cause confusion about the transfer process and possibly leave the resident and the resident representative unable to make an informed decision about the transfer. Findings: During a review of Resident 17's Face sheet (a document containing demographic information) dated December 19,2024, the Face sheet indicated, Resident 17 has a diagnosis of schizophrenia (a chronic mental illness that affects how a person thinks, feels, and behaves) and metabolic encephalopathy (a brain dysfunction that occurs when a chemical imbalance in the blood affects the brain). The face sheet also indicated who the resident representative, emergency contact, and guardian is (Resident Representative 1). During an interview on December 17, 2024, at 8:18 AM, with resident representative (RR 1), RR 1 stated, Last month [Resident 17] was sent to the hospital for vomiting dark liquid, I was told they…

    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 before2024-12-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 two sampled residents (Resident 51) reviewed for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) received care and services for skin breakdown as was specified in the resident's care plan (an individualized plan for the medical care of a resident) and physician's orders when: -Resident 51's low air loss mattress (a mattress that uses air to help prevent and treat pressure wounds, and to regulate temperature and moisture levels) was not set to the correct pressure as specified by physician orders. -Resident 51 did not have on heel protectors [device that provides cushioning, support, and pressure relief to the heel] while in bed. -Resident 51's Electronic Medical Record (EHR) included a nursing weekly summary (weekly progress note created by licensed staff) which inaccurately specified Resident 51's skin was intact. These failures had the potential for Resident 51's 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 37) reviewed for accidents had a fall mat (a cushioned mat which may aid in lessening the severity of injury during a fall) next to her bed as was specified in the resident's care plan (an individualized plan for the medical care of a resident). This failure had the potential for Resident 37 to sustain a serious injury during a fall in which the severity of the injury may have been lessened if the fall mat had been in place. Findings: During a review of Resident 37's admission Record (contains medical and demographic information), the admission Record, indicated Resident 37 was admitted on [DATE], with diagnoses which included dementia (a chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life), legal blindness, psychotic disorder (a severe mental disorder that causes abnormal thinking and perceptions), and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-19 · tag F0912 — isolated
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure five of five rooms (each occupied by four residents per room) had the minimum required square footage for each resident. This failure had had the potential for increased risk of accidents and injuries to occur within the room as a result of limited space for wheelchair and Hoyer lift access (a mechanical device that helps move people with limited mobility), limited space to accommodate resident care activities, increased risk for falls, and a potential delay in the evacuation of residents during an emergency. Findings: During an observation on December 16, 2024, at 9:59 AM, in room [ROOM NUMBER], there were four residents observed to occupy the room. During a review of the facility document titled, [name of facility] Census (a document which indicates the total number of residents within the facility and their room number) dated December 15, 2024, the document indicated there was a total of five rooms within the facility each of…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-12-19 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 daily staffing information was posted in a resident accessible area within the facility. This failure resulted in the inability of all 55 residents in the facility to have access to information regarding the staffing levels of licensed and unlicensed staff directly responsible for providing them care within the facility. Findings: During an observation on December 17, 2024, at 10:30 AM, near the facility's main entrance, the facility had posted staffing information which included Direct Care Service Hours Per Patient Day (DHPPD - the total number of actual direct care service hours performed by direct caregivers per patient day divided by the average patient census). This area was not accessible to residents within the facility. During a concurrent observation and interview on December 18, 2024, at 12:44 PM, with the Director of Staff Development (DSD), the DSD stated he was the individual responsible for posting the DHPPD staffing information. The DSD further stated the DHPPD staffing information 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-12-19 · tag F0577 — pattern
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 post the results of the facility's most recent survey in a place readily accessible to residents, in a universe of 55 residents (Residents 1 to 55), when the survey results were posted in a lobby area whose residents' lobby access door was set to remain locked at all times. This failure had the potential to cause the residents' inability to read the survey results and assess areas like safety, staff competency, and compliance with regulations, which directly impacts their well-being and quality of life within the skilled nursing facility. Findings: During an observation, and interview, with a Registered Nurse Supervisor (RNS 1) and a Licensed Vocational Nurse (LVN 1) on December 17, 2024, at 1:57 PM, the survey results binder was observed posted to a front lobby wall and one door was noted between the residents' living area and the front lobby area. RNS 1 and LVN 1 were seated at the front lobby reception area, and stated the door to the lobby was usually closed and automatically locked on the residents' side…

    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
  • No harm found · Bcited before2023-10-18 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record reviews, and facility policy review, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for 2 (Resident #2 and Resident #27) of 2 sampled residents reviewed for beneficiary notices. Findings included: Review of a facility policy titled, Medicare Termination Notification, dated November 2017, specified, Policies: 1. The facility shall provide a Notice of Medicare Non-Coverage/expedited notice to the beneficiary when: a. All covered services provided under Part A are terminated where the beneficiary has remaining SNF days available and the beneficiary continues to reside in the facility; The SNF ABN or one of the Medicare denial letters shall also be provided. The policy indicated, Notification Guidelines: 2. When a resident is covered on Medicare Part A: and covered services are terminated where the beneficiary has remaining SNF days available and continues to reside in the facility: a. Notify the resident/resident representative no later than 2 days prior to the last day of coverage in writing…

    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

“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 CRYSTAL SOLORZANO — 9 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 4 of 52.0+2.0 vs chain
Health inspection 4 of 52.1+1.9 vs chain
Staffing 4 of 52.9+1.1 vs chain
Quality measures 4 of 53.3+0.7 vs chain
The other 8 homes this chain runs (chain average 2.0★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
AHCST LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST49%since 06/20/2024
RENEW HEALTH GROUP LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST51%since 06/20/2024
COHEN, RACHELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL51%since 04/01/2015
DIONISIO, PAOLAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST49%since 06/20/2024
RUST, JADENIndividualINDIRECT OWNERSHIP INTERESTsince 06/20/2024
MARTINEZ, ADRIENNEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/16/2023
HAGE, JEANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2018
QUADROS, SYLVIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/28/2022

CMS files one row per role, so the 14 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$11.6M
Net patient revenuemost recent cost report
-10.7%
Operating marginrevenue minus expenses
$875K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 93%Medicare 2%Other / private 5%

About 93% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $875K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$629per resident / day
operating cost
$19,127per month
≈ monthly operating cost
$568per 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 555896. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, 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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