Haven Post Acute
1311 E Date St, San Bernardino, CA 92404 · For profit - Limited Liability company · 99 certified beds · (909) 882-3316 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- it has an abuse, neglect, or exploitation citation (F0602), cited Nov 2021
- 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
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $37,557 in federal fines (most recent 2024-03-10)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.3% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.1% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.8% | 0.8% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 7.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.1% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 4.8% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.0% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.4% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 6.0% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.5% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.5% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 34.8% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 19.4% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.16 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.36 | 1.57 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
35.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 57 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 36 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 35.8%CMS range 24.3–51.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 8.0–16.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 55.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 69.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 89.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 79.3% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 3.6–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.16 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 99 beds and averages 93.4 residents a day — about 94% occupied, or roughly 6 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 4.26 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.66 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 3.87 hrs/resident/day on weekends vs 4.43 on weekdays — 13% thinner on weekends. RN hours go from 0.38 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-03-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide adequate supervision, to a resident identified as having moderate risk of elopement (risk that refers to a situation where a resident, has a moderate likelihood or possibility of leaving the premises without authorization or supervision, wandering away from a controlled environment, which can pose safety risks for the individual) for one of three sampled residents (Resident 1), when Resident 1 ' s elopement and wandering care plan did not address the specific monitoring needs and frequency necessary to minimize the risk or prevent Resident 1 leaving a safe area without the facility ' s awareness on March 6, 2024, and had not been found for more than 72 hours. This failure had the potential to place Resident 1's health and safety at risk and for him to likely experience some serious adverse outcome, due to exposure of the (outdoor) elements, missed antipsychotic medications (drugs used to treat symptoms of psychosis (mental disorder…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited beforedisputed · IDR2026-06-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure safe oxygen administration in accordance with its policy for one of three sampled residents (Resident 2) when Resident 2 was connected to an oxygen concentrator (a machine which delivers oxygen) labeled, broken, on June 2, 2026. This failure had the potential to cause a decline in Resident 2's respiratory status, including decreased oxygen saturation (a measurement of how much oxygen the red blood cells are carrying in the blood), shortness of breath (difficulty breathing) and lung injury, placing Resident 2's health and safety at risk.During a review of Resident 2's admission RECORD (contains medical and demographic information), the admission RECORD indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included heart failure (a when the muscle of the heart is too weak to pump blood well), hypertension (a condition with high blood pressure), diabetes (a condition with a high sugar in the blood), chronic respiratory…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-30 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records by not documenting resident-reported falls for one (1) of three (3) sampled residents (Resident 1).This failure resulted in a medical record that did not reflect Resident 1 reported change of condition.Findings: During a review of Resident 1's face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included subsequent encounter for fracture (the patient is in the healing or recovery phase, receiving routine follow-up care) and Alzheimer's disease (the most common form of dementia, a brain disorder that slowly destroys a person's memory and thinking skills). During a review of Resident 1 ' s Minimum Data Set (facility assessment tool), dated March 3, 2026, under Section C, it indicated her Brief Interview for Mental Status (BIMS- screening tool to assess resident's cognition) score was 12. (A BIMS score of 8-12 suggests…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety when buildup of grime and debris were noted on the floor and walls of kitchen's walk-in refrigerator. This failure had the potential to result in accumulation of pathogenic microorganisms (germs or infectious agents that can cause disease) and attraction of insects or rodents, which could place the health and safety of 88 highly vulnerable residents who receives food from the kitchen at risk. Findings: During a concurrent observation and interview with the Dietary Supervisor (DS), on March 3, 2025, at 8:44 AM, in the kitchen, the walk-in refrigerator was inspected. There was buildup of grime and debris on the floors and walls, underneath the shelve racks. The DS acknowledged the finding, and stated it is unacceptable. The DS further stated the walk-in refrigerator should be free of grime and debris. During a concurrent interview and record review on March 5, 2025, at 9:09 AM, with the Administrator (Admin), the facility's policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-06 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure their weight change protocol was implemented for one of two residents (Resident 50) reviewed for nutrition when the Registered Dietitian Nutritionist (RDN) recommendations for Resident 50, which included weekly weights monitoring and administration of appetite stimulant (substances that increase hunger and food intake) were not carried out timely. These failures have the potential to place Resident 50 at risk for malnutrition (state of nutritional deficiency or imbalance that occurs when the body does not receive or absorb sufficient nutrients to meet its physiological needs), increasing the risk of further weight loss, frailty, and weakened immune function, muscle wasting, weakness, reduced mobility, and cognitive and psychological decline, potentially leading to confusion, lethargy, and depression. Findings: During a review of Resident 50's admission Record (contains demographic and medical information), it indicated Resident 50 was admitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-06 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that medications and treatment supplies were stored in accordance with the facility's policy and procedure when: 1. Two expired Central Line Trays (a kit containing the necessary supplies for maintaining a central venous catheter [long thin tube inserted into a large vein near the heart]) were found in the intravenous cart (IV cart- mobile cart used to store intravenous supplies) and were available for use. 2. Six different types of expired dressings (pads or materials applied directly to wounds to protect them, promote healing, and absorb fluids), in various quantities were found inside the treatment cart and were available for use. 3. A medication treatment cup filled with an unidentified cream was found underneath Resident 5's bed. These failures had the potential for the medical and treatment supplies to loss sterility and adhesive strength, increasing the likelihood of infection and ineffective wound care, placing 88…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-06 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 Pain Assessment and Management policy was implemented for one of two residents (Resident 214) reviewed for pain, when Resident 214's PRN (pro re nata; as needed) pain medication was not administered as ordered by the physician. This failure had the potential to put Resident 214 in unnecessary prolonged pain and discomfort and had the potential for increased suffering, delayed recovery, and reduced mobility, ultimately affecting the resident's overall well-being. Findings: During a review of Resident 214's admission Record (contains demographic and medical information), it indicated Resident 214 was admitted to the facility on [DATE], with the diagnoses for displaced intertrochanter fracture of the left femur (broken left hip), hypertension (elevated blood pressure), and type 2 diabetes mellitus (a condition where the body has trouble to regulating blood sugar.) During a review of Resident 214's Physician Orders, dated March 1,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-06 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate (determined by calculating the percentage of medication errors (observed or identified preparation or administration of medications or biologicals which is not in accordance with prescriber's order; manufacturer's specifications; or accepted professional standards and principles) observed during a medication administration observation) were not 5 percent or greater. There were three medication errors identified out of 33 opportunities for errors, affecting one of 8 residents (Resident 214), resulting in an overall medication error rate of 9.09 % when three of Resident 214's were not administered in accordance with prescriber's order and facility policy on March 4, 2025. This failure had the potential to place Resident 214 at risk for dangerously high blood sugar, increasing the risk of serious health complications including infection (when harmful bacteria, viruses or fungi enter the body and start growing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-06 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eight residents (Resident 214) reviewed for medication administration was free of significant medication error (observed or identified preparation or administration of medications or biologicals which is not in accordance with prescriber's order; manufacturer's specifications (not recommendations); or accepted professional standards and principles, which causes the resident discomfort or jeopardizes his or her health and safety) when three of Resident 214's medications were not administered in accordance with physician's order and facility policy on March 4, 2025. This failure had the potential to place Resident 214 at risk for dangerously high blood sugar, increasing the risk of serious health complications including infection (when harmful bacteria, viruses or fungi enter the body and start growing causing illness, delayed wound healing, and sepsis (severe infection that spreads through the blood and can damage organs or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for all four sampled residents (Residents 1, 2, 3, and 4). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Residents 1, 2, 3, and 4) when their requests for assistance with activities of daily living were not responded to promptly. Findings: During the review of Resident 1's admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included unspecified hyperlipidemia (increase levels of lipids - like cholesterol [waxy substance found in the blood] with high cholesterol increases the chance of heart problem). During interview and observation with Resident 1 on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure proper care was provided to prevent a pressure ulcer/injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one of four sampled residents (Resident 1). This failure placed Resident 1's health and safety at risk, when he developed a facility acquired sacrum (lower back/spine) pressure injury and right hip stage IV (full-thickness skin and tissue loss). Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disrupted blood flow to the brain), acute embolism and thrombosis of deep veins of right upper extremity (deep vein thrombosis, clots), hypertension (high blood pressure), hereditary and idiopathic neuropathy (sensory and motor nerves are affected). During a concurrent interview and record review, on August…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 11 citations
- Potential for harm · D2023-09-02 · tag F0609 — failed to report abuse allegations — isolatedTimely 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that an allegation of abuse was promptly reported to the Administrator, who is the Abuse Coordinator, and the appropriate agencies in accordance with the facility's policy and procedure, for one of three residents (Resident 1). This failure had the potential for an allegation of abuse to go uninvestigated and unreported thereby increasing the chances of harm to Resident 1. Finding: An unannounced visit was made to the facility on August 15, 2023, at 4:05 PM to investigate a complaint alleging that Resident 1 was physically abused by another resident. A review of Resident 1's face sheet (contains demographic information and diagnoses) indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses which included: difficulty walking, limitation of activities due to disability and a mild cognitive impairment (memory loss.) During an observation of Resident 1 on August 15, 2023, at 4:46 PM, Resident 1 was observed to have bruising…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-11-04 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy and procedure (P & P) review, the facility failed to ensure the food preparation sink was equipped with an air gap (backflow prevention to stop cross-connections and contamination by discharging water and waste across an unobstructed space (a gap of air) to prevent cross contamination. This failure had the potential to place 94 of 95 residents receiving meals prepared in the kitchen to foodborne illness related to cross contamination. Findings: During a concurrent observation and interview on November 1, 2021, at 8:03 AM, with the Dietary Services Supervisor (DSS), it was observed that the food preparation sink did not have an air gap. When asked what the importance of an air gap was, the DSS stated, The importance of the air gaps is no contaminated water, it doesn't back up and contaminate the food. The DSS acknowledged the food preparation sink did not have an air gap. During an interview on November 3, 2021, at 2:25 PM, with the Registered Dietician (RD), when asked what the purpose was of an air gap on food preparation sinks,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-11-04 · tag F0813 — patternHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility record review, the facility failed to: 1. Maintain temperature logs for the facility resident refrigerator, 2. Discard food items in the facility resident refrigerator by the use by date listed on each item. These failures had the potential to spread foodborne illness to residents who utilize the facility resident refrigerator. Findings: 1. During a concurrent observation and interview on November 4, 2021, at 7:53 AM, with the rehabilitation nursing assistant (RNA 1), the resident refrigerator temperature log was not posted on the resident refrigerator located in the staff break room. When asked about the resident refrigerator temperature log, RNA 1 stated, It should be on the refrigerator. RNA 1 acknowledged there was not a temperature log on the resident refrigerator for November 2021. During a follow up interview on November 4, 2021, at 8:18 AM with RNA 1, resident refrigerator temperature logs were unable to be located for the following months: -August 2021 -September 2021 -October 2021 A review of the facility policy and procedure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-11-04 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility record review, the facility failed to maintain infection control practices when: 1. One of six sampled residents (Resident 23) and two of two unsampled residents (Resident 60 and 61) had urinals in their rooms which were not labeled with room/bed number and/or resident's name. 2. Staff were observed entering Yellow Zone (residents in the Yellow Zone are considered Persons Under Investigation (PUIs) for COVID-19 (a contagious and potentially fatal respiratory virus) rooms without donning (putting on) the appropriate personal protective equipment (PPE - gown, gloves, isolation gown, face shield or goggles, and an N95 respirator (a mask that filters 95% of airborne particles). These failures had the potential to spread infectious disease to other residents and staff in the facility. Findings: 1a. During an observation on November 1, 2021, at 10:26 AM, in Resident 60's shared room, a urinal (a bottle for urination) was observed on Resident 60's night table. The urinal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-11-04 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity when one out of six sampled residents (Resident 94) was seen wearing only a hospital gown and had no personal clothing in their possession. This failure had a potential to cause embarrassment and limit socialization. Findings: During an observation and concurrent interview on November 1, 2021, at 7:55 AM, with a Resident, (Resident 94) it was noted that he was wearing a hospital gown. He stated that he had been in the facility about six weeks, and he had asked the staff, but he hadn't been able to get any clothes. He stated that his wife is not able to visit, and his family does not live in California. During an interview on November 1, 2021, at 10:00 AM, with the Social Services Director (SSD), she stated that when residents are admitted to the facility they try and have family bring in clothes, but when they are unable to bring them, the facility has clothes that can be provided to the resident. She stated that attempts were made to get clothing brought into the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-11-04 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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, interviews, and record review, the facility failed to ensure that residents were safeguarded from misappropriation of property when one out of six sampled residents (Resident 312) reported the loss of $2040 from his belongings upon admission, and the facility failed to report the incident to all the agencies listed within the facility policy. This failure had the potential for further allegations of misappropriation of property from residents to occur within the facility. Findings During a concurrent observation and interview on November 1, 2021, at 9:42 AM, with a Resident, (Resident 312) he was observed to have difficulty being able to see when he was feeling for his walking cane and then stated that he was blind. He reported that $2040 was missing from his belongings when he was admitted to the facility on [DATE]. He stated that he had reported the loss to staff, but nothing was investigated, so he contacted the police department on October 31, 2021 and filed a report. He stated that an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-11-04 · tag F0636 — isolatedAssess 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the smoking assessment for one of one resident (Resident 58) was completed within 14 days of admission. This deficient practice had the potential for place Resident 58 at risk for smoking related injuries by delaying accurately assessing Resident 58's safety awareness when smoking. Findings: During an interview on November 1, 2021, at 4:53 PM, with Resident 58, she stated that she smokes daily in the designated smoking area. During an observation on November 3, 2021, at 1:17 PM, in the smoking patio, Resident 58 was observed sitting on a chair, smoking, with staff supervision. During a review of Resident 58's admission Record (clinical record with demographic information), the admission Record indicated, Resident 58 was admitted to the facility on [DATE], with diagnosis which includes chronic obstructive pulmonary disease (lung disease that causes obstructed airflow from the lungs) and diabetes mellitus (an impairment in the way…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-11-04 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a smoking care plan was completed for two of twenty-nine residents (Resident 58 and 99) within seven days of admission. This deficient practice had the potential for placing Residents 58 and 99 at risk for smoking related injuries. Findings: 1. During an interview on November 1, 2021, at 4:53 PM, with Resident 58, she stated that she smokes daily in the designated smoking area. During an observation on November 3, 2021, at 1:17 PM, in the smoking patio, Resident 58 was observed sitting on a chair, smoking, with staff supervision. During a review of Resident 58's admission Record (clinical record with demographic information), the admission Record indicated, Resident 58 was admitted to the facility on [DATE], with diagnosis which includes chronic obstructive pulmonary disease (lung disease that causes obstructed airflow from the lungs) and diabetes mellitus (an impairment in the way the body regulates and uses sugar). A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-11-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility record review, the facility failed to implement interdisciplinary team (IDT-a meeting of clinical staff) recommendations to prevent future falls, following a fall with major injuries for one resident, Resident 91. This failure had the potential to result in injury related to fall precautions not being implemented. Findings: A review of the facility document titled admission Record, (a document that contains clinical and demographic data), the admission Record, indicated Resident 91 had been re-admitted to the facility on [DATE], with diagnoses which included, Multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord), and, Age-related osteoporosis .(a condition of significantly diminished bone mass due to long-standing imbalance between bone resorption and bone formation). During an interview on November 1, 2021, at 4:52 PM, with Family Member (FM 1), FM 1 indicated Resident 91 had a fall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-11-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to discontinue oxygen as per physician's order for one of six sampled residents (Resident 58) when oxygen was being administered at 5 liters (a unit of measurement) via a nasal cannula (a tubing that delivers oxygen through the nose) to a resident with a diagnosis of chronic obstructive pulmonary disease (COPD- a lung disease that causes obstructed airflow from the lungs). This failure had the potential for Resident 58's to lose the drive to breath due to diagnosis of COPD. Findings: During a concurrent observation and interview, on November 1, 2021, at 12:17 PM, with a Licensed Vocational Nurse 1 (LVN 1), inside Resident 58's room, Resident 58 was observed sitting at the edge of the bed. An oxygen concentrator (device containing pressurized oxygen which delivers oxygen to the resident) was observed to be supplying five liters per minute (LPM unit of measurement) via nasal cannula. LVN 1 stated that Resident 58 was on continuous oxygen.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-11-04 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 safety of residents when a mechanical lift and two laundry hampers were stored in front of one out of four emergency exits. This failure had the potential to cause harm and even death to residents needing to evacuate the facility in the event of a disaster such as a fire. Findings: During an observation on November 1, 2021, at 7:46 AM, a mechanical lift (a lift used to move residents who can not assist themselves) was seen stored in front of the emergency exit in the resident hallway. During an interview on November 1, 2021, at 7:48 AM, with a certified nursing assistant (CNA 3), she stated that the exit isn't used, it's only used if we had a fire or something, so the lift is stored there until meal tray passes are finished, and then it's moved. During an interview on November 1, 2021, at 7:55 AM, with a certified nursing assistant (CNA 4,) she stated that it's normal for the lift to be there, it's always stored there, that's where it is kept. During an interview on November 1, 2021, at 08:00 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$37,557 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $37,557 — penalty dated 2024-03-10
- Medicare payment denial — starting 2024-04-03 for 16 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to BVHC, LLC — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.3 | +0.7 vs chain |
| Health inspection | 4 of 5 | 3.0 | +1.0 vs chain |
| Staffing | 3 of 5 | 3.4 | -0.4 vs chain |
| Quality measures | 4 of 5 | 3.8 | +0.2 vs chain |
The other 11 homes this chain runs (chain average 3.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BROWN, OLIVER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2026 |
| CALABAZARON, REDENTOR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/14/2022 |
| FRAGANTE, ANNIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/03/2024 |
| HAGE, JEAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| MANHAS, MANJEET | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/18/2023 |
| MARTIN, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| THAPA, NISCHAL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/06/2024 |
CMS files one row per role, so the 14 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $795K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 056053. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-06, 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.