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Kearny Mesa Convalescent And Nursing Home

7675 Family Circle Drive, San Diego, CA 92111 · For profit - Limited Liability company · 98 certified beds · (858) 278-8121 Medicare & Medicaid certified

Call the home — (858) 278-8121 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 22 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (32% 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 (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)

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

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

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 5 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Pharmacy
7345 Linda Vista Rd Ste E
Grocery
7152 Linda Vista Rd · (858) 292-7986 · Call to confirm hours
Park
Kearney Villa Softball Fields · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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 increased7.7%10.2%15.4%better
Long-stay residents who lose too much weight1.5%4.0%5.4%better
Long-stay residents with a catheter left in their bladder2.6%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms29.3%7.3%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened3.6%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.0%13.7%18.9%better
Long-stay residents with pressure ulcers0.0%4.3%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control7.3%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 table3.8%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine84.0%93.2%79.4%typical
Short-stay residents rehospitalized after admission26.8%23.0%22.6%worse
Short-stay residents with an outpatient ER visit12.3%11.2%12.0%typical

* 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.

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.

68.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 454 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

68.0%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
67.7%U.S. median 56.6%
Met the expected recovery
0.86U.S. median 0.31
Therapy hours / resident / day
0.44hours / resident / day
Physical therapy
0.37hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 67.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 201 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.86 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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 SNF68.0%CMS range 63.1–72.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 8.1–13.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge67.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge67.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge54.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge95.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.7%CMS range 6.5–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.111.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.85
RN hours/ resident / day
1.27
LPN hours/ resident / day
2.30
Aide hours/ resident / day
4.42
Total nurse hours/ resident / day
0.71
RN hoursweekends
32.4%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 98 beds and averages 83.2 residents a day — about 85% occupied, or roughly 15 beds typically open. It usually has some room. 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 4.42 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.30 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.83 hrs/resident/day on weekends vs 4.66 on weekdays — 18% thinner on weekends. RN hours go from 0.90 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below the national median of 45%. 1 administrator has left in the past year.

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

3
deficiencies at the latest standard inspection (2025-05-08)
7
at the previous standard inspection (2022-03-17)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · D2026-06-25 · tag F0641 — isolated
    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 interview and record review, the facility failed to accurately code a resident's fall on the Minimum Data Set (MDS - a federally mandated resident assessment tool) for one of five sampled residents (Resident 2). This deficient practice placed all fall risk residents at risk for inaccurate plan of care triggers necessary for individualized safety precautions, quality measure (QM-grades clinical outcomes and physical well-being provided by the facility) calculations and reimbursement adjustments being reported to CMS.Findings:A review of Resident 1's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included history of Abnormalities of Gait (walking) and Mobility, and Mild Cognitive (pertaining to memory, judgement and reasoning ability). A record review of Resident 2's Minimum Data Set, dated [DATE] indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of eight points out…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-01 · 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 interview and record review, the facility failed to ensure a medication was administered as ordered, and to ensure unattended medications were not accessible to residents for one of five sampled residents (1). As a result, Resident 1 had an increased risk of pain from the missed medication, and residents were at risk of accidental ingestion or exposure to unattended medications left on the floor.Findings: Per the facility's admission Record, resident 1 was admitted to the facility on [DATE] with diagnoses to include anxiety. Per the facility's Progress Notes, there were no notes documented for Resident 1 on 3/11/26. Per the facility's Progress Note dated 3/12/26 at 9:45 A.M., the Director of Nursing (DON) documented, Visited with resident at bedside earlier this morning, regarding medications from last night.Resident handed 2 capsules which pt (patient) states are her [pregabalin] (a pain medication) and gabapentin (a pain medication) Per the facility's Controlled Drug Record for Resident 1, dated…

    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 · D2025-05-08 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and facility policy review, the facility failed to ensure the comprehensive care plan was revised to accurately reflect the information in the comprehensive assessment, which affected 1 (Resident #61) of 4 residents reviewed for advance directives. Specifically, the facility failed to revise Resident #61's care plan to reflect the resident's code status listed in the comprehensive assessment. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy revealed, 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Minimum Data Set] assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission). The policy indicated, 11. Assessments of residents are ongoing and care…

    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 · D2025-05-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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, record review, and facility policy review, the facility failed to obtain orders for the use of a non-invasive mechanical ventilator (specifically, continuous positive airway pressure; CPAP) timely, which affected 1 (Resident #184) of 3 residents reviewed for respiratory care . Findings included: A facility policy titled, CPAP/BiPAP [bilevel positive airway pressure] Support, revised 03/2015, directed staff under a Preparation section to 2. Review the physician's order to determine the oxygen concentration and flow and the PEEP [positive end-expiratory pressure] pressure (CPAP, IPAP [inspiratory positive airway pressure] and EPAP [expiratory positive airway pressure]) for the machine. An admission Record indicated the facility admitted Resident #184 on 04/19/2025. According to the admission Record, the resident had a medical history that included a diagnosis of chronic diastolic congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD)…

    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 before2025-05-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure respiratory equipment (specifically, continuous positive airway pressure; CPAP equipment) was stored appropriately, which affected 1 (Resident #184) of 3 residents reviewed for respiratory care . Findings included: An admission Record indicated the facility admitted Resident #184 on 04/19/2025. According to the admission Record, the resident had a medical history that included a diagnosis of chronic diastolic congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #184 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #184's Care Plan Report did not include information on the use of a non-invasive mechanical ventilator. Resident #184's Order Summary Report, for active orders as of 05/07/2025, included the following orders, each with an order date of 05/07/2025: -CPAP/APAP (automatic positive airway pressure): setting from 6.0 to 20.0 centimeter of water…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-21 · 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 observation, interview and record review, the facility failed to perform abdominal assessment and verify Resident 1 ' s appointment prior to sending to Interventional Radiology (IR) clinic. As a result , Resident 1 was left outside of the clinic in a cold weather close to an hour and not needed to be seen at the clinic. Findings: A review of Resident 1 ' s admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Hydronephrosis with renal and ureteral calculous obstruction( excess fluid in the kidney due to a backup of urine) and Osteomyelitis of the lumbar region (inflammation of the lower back). A review of the hospital record titled, service encounter dated 12/18/24 Hospitalist, History and Physical indicated, in October 2024, Resident 1 had a rising white blood count and had an interloop (to loop together) collection that underwent an IR drainage after which the catheter was removed on November 22, 2024. During an interview on 12/23/24 at 10:26 A.M.,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-25 · 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 interview and record review the facility failed to provide supervision for one of two residents (Resident 1) when Resident 2's wandering (moving from place to place) behavior was not identified which resulted to an altercation with Resident 1. This failure had the potential for Resident 1's safety and wellbeing. Findings: Review of Resident 1's admission Record indicated, Resident 1 was admitted on [DATE] to the facility with diagnoses that included Chronic Pain Syndrome, and dependent on wheelchair use. A review of Resident 2's admission Record indicated, Resident 2 was admitted on [DATE] to the facility with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory), and Dementia (a group of thinking and social symptoms that interferes with daily functioning). An interview on 5/28/24 at 10:30 A.M., with Resident 1 was conducted. Resident 1 stated Resident 1 was sitting on her wheelchair in her room when Resident 2 came from behind. Resident 1 stated she told Resident 2 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 · D2022-03-17 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop a care plan for one of one resident (173) on dialysis (a process of cleaning blood) with fluid restriction. As a result Resident 173 had the potential for fluid overload. Findings: Resident 173 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis per the facility's admission Record. On 3/16/22, a review of Resident 173's records was conducted. The physician order, dated 3/3/22, indicated fluid restriction of 1,600 milliliters (ml)/day. There was no documented care plan for Resident 173's dependence on dialysis and the ordered fluid restriction. On 3/16/22 at 2:52 P.M., a concurrent interview and record review of Resident 173's records with LN 6 was conducted. LN 6 stated there should be a care plan for dialysis and fluid restriction for Resident 173. Per the facility's policy and procedure titled Care Plans- Comprehensive and revised 10/17, Policy Statement: An individualized comprehensive care plan…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-03-17 · 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 the staff followed a physician's orders for one of one resident (Resident 173) on dialysis (a process of cleaning blood) when: 1. The staff did not follow the fluid restriction order 2. The staff took blood pressure measurement on the resident's vascular access arm As a result, 1. Resident 173 was given more fluids than what was ordered 2. There was a potential for vascular access complication Findings: Resident 173 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis per the facility's admission Record. 1. On 3/16/22, a review of Resident 173's records was conducted. The physician order dated 3/3/22 indicated fluid restriction of 1600 milliliters (ml)/day- dietary 960 ml/day, nursing 640 ml/day and to document amount of fluid consumed. On 3/16/22 at 10:16 A.M., an interview with Resident 173's family member (FM) was conducted. The FM stated the facility staff did not inform her there was an order for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-17 · 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 did not ensure a pressure relieving mattress was set up according to the physician's order for one of five sampled residents (320) with pressure ulcers (areas of damaged skin caused by staying in one position for too long). This failure had the potential to cause Resident 320's pressure ulcer to deteriorate. Findings: Resident 320 was admitted to the facility on [DATE], with a diagnoses of stage 2 Pressure ulcer of sacral region and aftercare following surgery of the digestive system, per the facility's admission Record. A review of the Braden Scale for Predicting Pressure Sore Risk , dated 3/10/22, indicated Resident 320 was at risk, slightly limited mobility, makes frequent though slight changes in body independently. During an observation on 3/14/22, at 8:40 A.M., in Residents 320's room, Resident 320 was in bed, on a low air loss mattress (LAL, alternating pressure low air loss mattress; reduces pressure to aid in the prevention and treatment…

    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
Show the remaining 12 citations
  • Potential for harm · Dcited before2022-03-17 · 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 revise fall specific preventative measures for one of one resident (Resident 61), after a fall. As a result, Resident 61 suffered another fall six days later after the initial fall. Findings: Resident 61 was admitted to the facility on [DATE] with diagnoses which included abnormalities of gait and mobility and dementia (impaired memory) per the facility's admission Record. On 3/15/22 at 9:31 A.M., Resident 61 was observed in bed, leaning towards the right side. Resident 61 was grasping the right siderail of the bed with both hands and attempting to pull himself up. His right leg was off to the right side of the bed. He was wearing a brief, which appeared to be wet. On 3/17/22 at 9:28 A.M., an interview was conducted with CNA 1. CNA 1 stated Resident 61 had an incontinent of bladder (having no or insufficient voluntary control over urination). CNA 1 stated Resident 61 was a fall risk. CNA 1 further stated she heard Resident 61 fell before…

    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 · D2022-03-17 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services 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 staff provided the services required for the care of one of one resident (Resident 173) on dialysis (a process of cleaning blood) when: 1. The staff did not remove the dressing on the dialysis vascular access per the dialysis center recommendation 2. The staff did not accurately identify the dialysis access' bruit (sound of blood flow) and thrill (vibrations of blood flow) As a result, there was a potential a dialysis access complication would not be identified. Findings: Resident 173 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis per the facility's admission Record. 1. On 3/16/22, at 10:16 A.M., an observation of Resident 173's left arm was conducted. A gauze dressing was noted on Resident 173's left upper arm. On 3/16/22, at 2:37 P.M., a concurrent interview and record review with LN 6 was conducted. LN 6 stated Resident 173 has a dialysis access on the left upper arm and his…

    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 before2022-03-17 · 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 the staff followed the physician's order for one of three sampled residents (20) for pain medication. This failure had the potential for Resident 20's pain to be unrelieved. Findings: Resident 20 was admitted to the facility on [DATE], with a diagnoses of cellulitis (bacterial skin infection) of bilateral lower limbs and chronic pain syndrome (pain that lasts for over 3 months that can interfere with daily activities), per the facility's admission Record. During a clinical record review conducted for Resident 20, per the physician's order dated 2/20/22, Norco (medication for pain) tablet 5-325 mg (Hydrocodone-Acetaminophen), give 1 tablet by mouth every 4 hours as needed for moderate (5-7 pain scale), to severe pain (8-10 pain scale) and dated 7/25/21, Hydromorphone HCL tablet 2 mg (medication for pain) give 1 tablet by mouth every 4 hours as needed for break through pain A concurrent observation and interview with Resident 20 on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-17 · tag F0888 — isolated
    Ensure staff are vaccinated for COVID-19
    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 decrease the transmission of COVID-19 to residents when: 1. the facility's staff vaccination policy was not in accordance with federal regulation 2. an unvaccinated staff member did not wear the required protective facial covering. These failures had the potential to contribute to the transmission and spread of COVID-19 to residents, staff, and visitors in the facility. Findings: 1. An interview with the facility's ICP was conducted on 3/16/22 at 2:06 P.M. The ICP stated the facility's staff vaccination policy was reviewed and updated as needed according to state and federal guidelines, adhering to the stricter regulation. On 3/16/22, at 3:50 P.M., a concurrent interview and record review of the facility's policy titled, Health Care Worker Vaccine Requirement, revised on 3/1/22, was conducted with the ICP. Per the facility's policy under Exemption .2 .unvaccinated exempt worker must meet the following requirements when entering of working in the facility .b. Wear a surgical mask or higher-level respirator at…

    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 · D2019-09-20 · 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 treat residents in a dignified manner when: 1. Staff did not answer call bells in a timely manner for 2 of 19 sampled residents (20, 21), 2. Staff did not knock prior to entering a residents' room and bathroom for one of 19 sampled residents (Confidential Resident 5), and; 3. A resident (34) waited 55 minutes before receiving pain medication. These failures resulted in Resident 20 having accidents, Resident 21 feeling unimportant, Confidential Resident 5 feeling embarassed and Resident 34 feeling neglected because her pain was not managed in a timely manner Findings: 1A. Resident 20 was admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs), per the facility's admission Record. Per the MDS (an assessment tool), dated 9/3/19, Resident 20 had a BIMS (a cognitive test) of 13 out of 15 (a score of 13-15 indicates a resident is cognitively intact), which indicated the resident was mentally…

    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 · D2019-09-20 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 nursing staff followed the dietary cards during a meal observation for two of seven randomly observed residents (47, 49). This failure had the potential to cause aspiration (breathing foreign objects into the airways, such as food or liquids) for the residents. Findings: On 9/17/19 at 11:53 A.M., a lunch observation of residents in the dining room was conducted. At 11:58 A.M., the CCC set up the tray for Resident 47, including putting a straw into the orange juice. At 11:59 A.M., the CCC set up the tray for Resident 49, including putting three straws into a vegetable juice, a milk container, and a shake. On 9/17/19 at 12 P.M., a record review of the residents' dietary cards was conducted. Resident 47's and Resident 49's dietary cards were next to their meals and indicated no straws. On 9/17/19 at 12:06 P.M., an interview and record review was conducted with the CCC. The CCC stated she had set up the trays for both Resident 47 and Resident 49. The CCC further stated she had read both of the cards 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's code status was formulated for 1 of 19 sampled residents (30). This failure had the potential to administer the incorrect care or treatment to Resident 30 during an emergency. Findings: Resident 30 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia (a decreased amount of oxygen in the blood), per the facility's admission Record. On [DATE] at 4:55 P.M., a record review of Resident 30's medical record was conducted. The POLST (a document indicating life sustaining treatment and end-of-life care) was not filled out to indicate if the resident wished to receive CPR (a lifesaving technique used during an emergency) or not and it was not signed by the resident or the physician. The code status field in Resident 30's electronic medical record was blank. There was no physician's order to indicate Resident 30's code status. On [DATE] at 10:18 A.M., an interview was conducted with 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-20 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a nurse followed a physician's order when a Lidocaine (a medication that relieves pain and numbness) patch was not removed for one of four residents (219) observed during medication pass. This failure had the potential for the resident to be over medicated. Findings: Resident 219 was admitted to the facility on [DATE] per the facility's Transfer/Discharge report. On 9/19/19 at 8:07 A.M., a concurrent observation and interview of Resident 219 was conducted with LN 24 during a medication administration. When LN 24 attempted to place a Lidocaine patch on Resident 219's neck, the patch from the prior day was observed to still be on the resident's neck. LN 24 stated the patch should not have been there. LN 24 stated, per the schedule, the patch should have been removed 12 hours after application on the evening of 9/18/19 at 9 P.M. LN 24 removed the patch and applied the new patch. On 9/19/19, a review of Resident 219's medical record was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-20 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 respond to the pharmacist's monthly MRR for one of five residents reviewed for unnecessary medications (10). This deficient practice had the potential to cause adverse consequences related to medication therapy. Findings: Resident 10 was admitted on [DATE] with diagnoses which included, dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), per the admission Record. On 9/17/19 at 9:35 A.M., Resident 10 was observed in bed with eyes closed. Resident 10 had stitches on the right side of her forehead. The right side of her face was black and blue. On 9/19/19, Resident 10's record was reviewed. A review of documents titled, Consultant Pharmacist's MRR were conducted. The MRR dated 2/4/19 indicated, Resident has been on the same dose of Risperdal (a medication to treat schizophrenia) 0.25mg q am (every morning) and 0.5mg q hs (every bedtime) since 8/18 .GDR is due if…

    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 · D2019-09-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility failed to ensure a licensed nurse dated a multi-dose vial of Aplisol (a solution used to test for tuberculosis- a lung disease) when opening it. As a result, staff would not know when the Aplisol would be expired. Findings: On 9/19/19 at 9:22 A.M., a concurrent observation and interview was conducted with LN 25 in the medication storage room B. An opened 1-milliliter (ml) vial of Aplisol Lot # 328705 was observed in the medication room refrigerator. The vial did not have an open date written on it. LN 25 stated the vial had been opened and not dated. LN 25 stated the vial should have been dated because the solution would expire 28 days after it had been opened. RN 25 then placed the vial back into the refrigerator. On 9/19/19 at 9:50 A.M., an interview was conducted with LN 26. LN 26 stated all multidose vials of medications needed to be dated when opened so nursing staff would know when to discard them. On 9/19/19 at 11:04 A.M., an interview was conducted with the DSD. The DSD stated when opening a multidose vial, the nurse needed to date it so nursing staff would know…

    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 · D2019-09-20 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received specialized rehabilitative services as determined by the occupational therapy's comprehensive plan of care for 1 of 19 sampled residents (21). As a result, Resident 21 did not meet his goal of walking with a prosthetic leg. Findings: Resident 21 was admitted on [DATE] with diagnoses which included right leg below the knee amputation, per the facility's admission Record. On 9/17/19 at 7:40 A.M., Resident 21 was observed awake, alert and sitting up in bed. Resident 21 had a right below the knee amputation. On 9/18/19 at 3:05 P.M., Resident 21 was interviewed. Resident 21 said, I had my right leg amputated last year. I came to this facility for rehab. I requested a prescription for a prosthetic leg three months ago and have not heard anything about it. On 9/19/19 at 10:05 A.M., the DOR was interviewed. The DOR said, The resident started rehab on 5/2/19. He completed physical therapy and occupational therapy. His…

    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 before2019-09-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure visitors followed the proper procedures when visiting a resident on contact precautions (a set of procedures to minimize the transmission of infectious organisms by direct or indirect physical contact with an infected resident) for 1 of 1 residents on transmission based precautions (29). In addition, the facility failed to ensure staff performed hand hygiene when assisting residents in the dining room. These failures had the potential to spread infection to other residents. Findings: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses which included zoster (a virus that causes chickenpox or shingles, which is spread by touching someone who actively has the virus) without complications, per the facility's admission Record. On 9/17/19 at 9:12 A.M., during a tour of the facility, there was a sign posted outside of Resident 29's door indicating to see the nurse before entering the room along with PPE (protective gowns,…

    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

“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 GENERATIONS HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 54.1+0.9 vs chain
Health inspection 5 of 53.6+1.4 vs chain
Staffing 2 of 53.7-1.7 vs chain
Quality measures 5 of 54.6+0.4 vs chain
The other 26 homes this chain runs (chain average 4.1★, per CMS)
2 of 5Horizon Health & Subacute CenterFresno, CA 2 of 5Temecula Healthcare CenterTemecula, CA 2 of 5Walnut Creek Skilled Nursing & Rehabilitation CentWalnut Creek, CA 3 of 5Canyon Oaks Nursing And Rehabilitation CenterCanoga Park, CA 3 of 5English Oaks Convalescent & Rehabilitation HospitaModesto, CA 3 of 5Newport Nursing And Rehabilitation CenterNewport Beach, CA 3 of 5Smith Ranch Skilled Nursing & Rehabilitation CenteSan Rafael, CA 3 of 5The Bradley GardensSan Jacinto, CA 4 of 5Bayberry Skilled Nursing & Healthcare CenterConcord, CA 4 of 5Castle Manor Nursing & Rehabilitation CenterNational City, CA 4 of 5Cedar Crest Nursing And Rehabilitation CenterSunnyvale, CA 4 of 5Coronado Ridge Skilled Nursing & Rehabilitation CeHenderson, NV 4 of 5Gramercy CourtSacramento, CA 4 of 5Lompoc Skilled Nursing & Rehabilitation CenterLompoc, CA 5 of 5Anberry Nursing And Rehabilitation CenterAtwater, CA 5 of 5Arbor Hills Nursing CenterLa Mesa, CA 5 of 5Bradley CourtEl Cajon, CA 5 of 5Friendship Manor Nursing & Rehab CenterNational City, CA 5 of 5Heritage Park Nursing CenterUpland, CA 5 of 5Lakeside Special Care CenterLakeside, CA 5 of 5Lawton Skilled Nursing & Rehabilitation CenterSan Francisco, CA 5 of 5Pleasanton Nursing And Rehabilitation CenterPleasanton, CA 5 of 5Plum Tree Care CenterSan Jose, CA 5 of 5Siena Skilled Nursing & Rehabilitation CenterAuburn, CA 5 of 5Stanford Court Skilled Nursing & Rehab CenterSantee, CA 5 of 5Vista Manor Nursing CenterSan Jose, CA

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

Who owns this facility

Owner / managerTypeRoleSince
BMO BANK NATIONAL ASSOCIATIONOrganization5% OR GREATER SECURITY INTERESTsince 10/06/2021
MASTROCOLA, LOISIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICERsince 02/01/1998
OLDS, THOMASIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 02/01/1998

CMS files one row per role, so the 6 rows in the source record cover these 3 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.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$17.3M
Net patient revenuemost recent cost report
+1.4%
Operating marginrevenue minus expenses
$2.2M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 3%Medicare 39%Other / private 58%

This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$597per resident / day
operating cost
$18,158per month
≈ monthly operating cost
$606per 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 055286. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-08, 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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