Central Gardens Post Acute
1355 Ellis Street, San Francisco, CA 94115 · For profit - Limited Liability company · 92 certified beds · (415) 567-2967 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- 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
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 4.5% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.6% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.3% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.9% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 22.6% | 7.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.4% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 0.0% | 9.8% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 2.0% | 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 | 3.3% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.5% | 10.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.0% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.6% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.0% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.2% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.65 | 2.25 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.41 | 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.
59.7% 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 285 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 81.1% 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 164 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 0.52 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 59.7%CMS range 53.9–64.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 8.5–14.1 | 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 | 81.1% | 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 | 77.4% | 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 | 68.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 92.2% | 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 | 8.2%CMS range 5.6–10.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.24 | 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 92 beds and averages 87.8 residents a day — about 95% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.80 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 3.44 hrs/resident/day on weekends vs 3.94 on weekdays — 13% thinner on weekends. RN hours go from 0.95 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · D2025-02-20 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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, record review, and facility policy review, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (PASARR) accurately reflected the presence of diagnosed mental illnesses for 1 (Resident #7) of 3 residents reviewed for PASARR requirements. Specifically, Resident #7 had a Level I PASARR completed upon readmission to the facility that did not reflect all their mental health diagnoses. Findings included: An undated facility policy titled, admission Criteria, indicated, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. Resident #7's admission Record indicated the facility originally admitted the resident on 10/03/2020 and most recently admitted the resident on 05/04/2024. According to the admission Record, the resident had a medical history that included diagnoses of delusional disorders and schizophrenia.…
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 before2025-02-20 · 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
Based on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of less than 5 percent (%). Specifically, the facility had 2 errors out of 30 opportunities, resulting in a medication error rate of 6.67 %, affecting 1 (Resident #39) of 6 residents observed during medication administration. Findings included: A facility policy titled Medication Administration, revised 04/2019, indicated, 10. The individual administering the medication verifies the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. An admission Record revealed the facility admitted Resident #39 on 07/19/2024. According to the admission Record, Resident #39 had a medical history that included a diagnosis of unspecified bipolar disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/22/2025, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #39's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) when providing care to 1 (Resident #155) of 1 resident requiring EBP observed during the provision of care. Specifically, staff failed to wear a gown during resident care that consisted of touching the resident and their feeding tube. Findings included: An admission Record revealed the facility admitted Resident #155 on 02/08/2025. According to the admission Record, Resident #155 had a medical history that included a diagnosis of gastrostomy (surgical procedure to create an opening in the abdominal wall into the stomach) status. Resident #155's Care Plan Report included a focus area, initiated on 02/08/2025, that indicated the resident required tube feeding related to dysphagia (difficulty swallowing). The Care Plan Report also included a focus area, initiated on 02/17/2025, that indicated the resident required EBP during high-contact resident-care activities due to the presence of an indwelling medical device (feeding tube). During a concurrent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-25 · tag F0609 — failed to report abuse allegations — patternTimely 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 Interviews and record reviews, the facility failed to ensure the allegation of resident-to-resident abuse was promptly reported to the State Agency (SA, which is the California Department of Public Health, CDPH) in accordance with the facility ' s policy and procedure for four of 4 sampled residents (Resident 1, Resident 2 Resident 3, and Resident 4). Failure to promptly report allegation of abuse had the potential for further abuse to happen and thereby increasing the chances of harm to the residents. Findings: During a review of admission Record, dated [DATE], indicated, Resident 1, admitted to facility on [DATE], with diagnoses including: Seizures (involuntary body jerking), Adult failure to thrive, Dementia (loss of memory). Resident discharged on [DATE]. Review of admission record, dated, [DATE], indicated, Resident 2, admitted to facility on [DATE] with diagnoses including: Compression Fracture Lumbar, Cirrhosis of Liver ( damaged liver from various causes) , Malignant Neoplasm of Larynx (Cancer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-25 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure baseline care plan was developed within 48 hours of admission for Resident 6 and a copy of the baseline care plan summary was provided to the resident and/or representative for three of 3 sampled residents (Resident 5, 6, and 7). A Baseline Care Plan (BCP) includes minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline, injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. The deficient practice resulted in Resident 5, 6, and 7, and/or RP not receiving information of the initial plan of care; and had the potential to result in inadequate care and services rendered to the residents. Findings: Review of Resident 5 ' s admission record indicated, admitted to facility on 4/11/24 with diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-27 · 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 interview, record review, and observation, the facility failed to provide needed care and assistance in accordance with professional standards of practice when Resident 1, one of one sampled residents, did not receive pain medication or bathroom assistance, throughout the entire night. This failure caused undue suffering and neglect to the resident. Findings: Resident 1 was admitted to the facility on [DATE], at 3:30 PM, for Physical Therapy and Occupational Therapy services after transfer from hospital. Resident 1's diagnoses included, lumbar fracture from fall, back surgery from fall fracture, back pain, high blood pressure, gout (inflammatory joint pain and swelling), urinary tract infection, and liver disease. Required assistance with toileting, transferring, bathing and dressing. Resident is not incontinent of urine (has control of her urine). Alert and oriented, denied pain upon admittance. Resident was medicated prior to transfer from hospital. Resident is [AGE] years old and does not speak…
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 before2023-05-26 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 maintain a medication error rate less than five percent for two out of seven Residents observed (Residents 53 and Resident 8). This created an error rate of 9.68 percent (3 errors out of thirty-one opportunities). This failure had the potential to cause worsening medical conditions for each resident. Findings. 1. Symbicort was not administered during the appropriate time frame for Resident 53 (omission of medication). 2. Depakote delayed release tablets was crushed and administered for Resident 8. 3. Lidocaine patch was not applied to Resident 8 and documented as administered (omission of medication). 1. During an observation on 5/23/23 at 9:49 AM in Resident 53's room, it was observed that licensed vocational nurse (LVN) 1 administered tablet medications only to Resident 53. It was observed that Resident 53 was offered stool softeners, and that Resident 53 refused the stool softener. Review of Resident 53's Medication orders 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.
- Potential for harm · Ecited before2023-05-26 · 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 record review, the facility failed to provide a safe and sanitary environment when: 1. The Red Zone (isolation room) door, with Resident 434 inside, was fully open while staff was cleaning the room. 2a. A dirty urinal was hung on the side rail of Resident 44's bed on 5/23/23. 2b. Resident 44's urinal jug containing urine was placed on the overbed table. 3. Staff did not perform hand hygiene after glove removal. 4. Staff did not perform hand hygiene when she entered between two residents' rooms. 5. Staff did not clean and disinfect medical equipment (blood pressure cuff) in between multiple residents (Resident 39, Resident 53, and Resident 44). These failures had the potential for cross contamination of infection that can compromise the health and safety of the residents and the potential to spread infectious disease from one resident to another. Findings: 1. Resident 434 was admitted on [DATE] with diagnoses including septicemia (an infection that occurs when germs get into…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-26 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to create a baseline care plan based on physician admitting order of one of three residents (Resident 78) reviewed when Resident 78 admitted [DATE] with enteral feeding order, care plan was only initiated on 5/24/23. This failure can result in Resident 1 not getting tube feeding as ordered. Findings: Review of Resident 78's admission Record indicated, admitted to facility on 5/15/23 with diagnosis including Dysphagia (difficulty in swallowing), Esophageal Cancer (cancer of the tube that runs from the throat to the stomach). Review of Physician Order dated 5/17/23, indicated, Enteral Feed (form of nutrition delivered into the digestive system as liquid) Order, Jevity 1.5 at 100 ml/hr x 8 hours (9:00 PM-5:00 AM), one time in the evening. Review of Care Plan, indicated, resident requires tube feeding r/t (related to) esophageal cancer s/p (status post, after) esophagectomy (removal of esophagus), esophageal stricture initiated 5/24/23. Interview on 5/25/23…
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 · D2023-05-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement fall care plan for one of three sampled residents (Resident 6) when there was no landing pad (known as fall mat) in place after his fall incident on 2/20/23. This failure placed Resident 6 at risk for injury from another fall. Findings: Review of Resident 6's clinical record indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses including mild cognitive impairment (a condition where people experience memory and thinking problems), hypertension (high blood pressure), and history of falling. Review of Resident 6's MDS (Minimum Data Set, an assessment tool), dated 12/3/22 and 5/7/23, indicated, Resident 6 was severely cognitively impaired. During a concurrent observation and interview on 5/25/23, at 9:21 AM, with Certified Nursing Assistant (CNA) 2, in Resident 6's room, there was no landing pad in place. There was no sign in Resident 6's room and at the door indicating that he was at high risk of falling. CNA…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2023-05-26 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise the fall care plan for one of three sampled residents (Resident 6) after his fall incident on 10/26/22. This failure had the potential to put Resident 6 at risk for another fall. Findings: Review of Resident 6's clinical record indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses including mild cognitive impairment (a condition where people experience memory and thinking problems), hypertension (high blood pressure), and history of falling. Review of Resident 6's MDS (Minimum Data Set, an assessment tool), dated 12/3/22 and 5/7/23, indicated, Resident 6 was severely cognitively impaired. During a concurrent observation and interview on 5/23/23, at 11:17 AM, with Resident 6, in his room, Resident 6 was sitting in wheelchair. He was confused with time and place when asked. During an observation on 5/25/23, at 9:23 AM, in hallway, Resident 6 was sitting in wheelchair, and roaming around in the hallway by…
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 · D2023-05-26 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 maintain an accurate accountability sheet that documented the number of controlled substances (Oxycodone tablets, pain medication) that should be available for destruction, and an accurate count of controlled substance (Oxycodone tablets) physically available for destruction compared to the documented amount that should be available for destruction for one out of eight residents reviewed (Resident 441). This failure has the potential to cause medication diversion (illegal use of medication not intended by the provider). Findings: Review of Resident 441 admission Record indicated that Resident 441 was admitted on [DATE], with the medical diagnosis including left hip osteoarthritis (joint and bone disease which causes pain and stiffness), pain in left lower leg, and kidney failure. Resident 441 was discharged from the facility on 1/09/23. During a concurrent interview and observation on 5/24/23 at 11:00 AM, with the Director of Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 store controlled substances intended for destruction in a separately locked and permanently affixed storage compartment when Oxycodone (controlled substance for pain) tablets and solutions were found on the floor, and in a cardboard box in plain sight, for one out of seven Residents reviewed (Resident 441). This failure had the potential to cause medication diversion (illegal use of medication not intended by the provider). Findings. Review of Resident 441 admission Record indicated that Resident 441 was admitted on [DATE], with the medical diagnoses including left hip osteoarthritis (joint and bone disease causing pain and stiffness) , Pain in left lower leg, and kidney failure. Resident 441 was discharged from the facility on 1/09/23. During concurrent observation and interview on 5/24/23 at 10:30 AM in the Director of Nursing (DON) office, it was observed that packaged Oxycodone tablets (controlled substance that has a high risk for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-26 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and, record review, the facility failed to accommodate food preferences of one of nine sampled residents (Resident 11) when she was served cheeseburger instead of the preferred pork vegetable stir fry during lunch on 5/25/23. This deficient practice had the potential for Resident 11 to experience an unpleasant dining experience due to receiving foods she did not request or like. Findings: Review of Resident 11's admission Record, indicated Resident 11 was admitted on [DATE]. Review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 4/27/23, indicated Resident 11 was cognitively intact. During a concurrent observation and interview on 5/25/23 at 12:50 PM, Resident 11 was in her room, eating a cheeseburger. Resident 11 stated I had cheeseburger for lunch and dinner yesterday, and lunch today. I did not request for an alternate menu, so I don't know why I'm having a cheeseburger again. During a concurrent observation of Resident 11 and interview on 5/25/23 at 1:01 PM,…
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 · F2019-10-04 · 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 service safety when: A. 16 cups of juices, six thickened milk were not dated and not labeled; B. The refrigerator for resident food in nurse station A was not clean; C. Three cutting boards had rough, deep scratches; one cutting board had dark residue on the surface; D. Four large sheet pans had dark brown/ black thick residue on the inside surface; E. Three muffin pans had dark brown and sticky yellow residue on the inside surface; and F. Three non stick pans had rough, scratched inside coating; one with broken handle. These failures had the potential to cause food borne illness for 83 residents who received food from the kitchen out of the facility census of 83. Findings: A. During the kitchen observation and concurrent interview on 10/1/19 at 8:58 AM, 16 cups of juices and six cups of thickened milk were found not dated and not labeled in refrigerator two. The Kitchen Supervisor stated, we do not label them. Review of facility's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-10-04 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to prevent the development and transmission of communicable diseases and infections when: 1. CNA 2, without wearing gloves, transported unbagged, soiled laundry from a resident's room to a hamper in the shower room. 2. An unlabeled, uncovered urinal, with scant yellowish liquid, was found on Resident 13's bedside table. 3. Licensed Vocational Nurse (LVN) 1 did not observe infection control techniques when administering Resident 10's eye drop medication. 4. LVN 1 did not handwash in between patient care. 5. Multi resident use glucometer was not disinfected according to disinfecting wipes' directions for use 6. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene while feeding three residents (Residents 1, 31 and 57). This failure had the potential to spread communicable diseases and infections from one resident to another. Findings: 1. During observation of Certified Nursing Assistant 2 (CNA 2) 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 · E2019-10-04 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to give adequate and timely notice of Medicare coverage end date for three of three sampled residents, Resident 7, Resident 30, and Resident 84, when: 1. No evidence Resident 7 received Notice of Medicare Non Coverage (NOMNC - a notice that informs Residents of their Medicare Part A coverage end date and how to appeal). 2. Residents 30 and Resident 84 received NOMNC on the same day their coverage ended. These failures resulted in Resident 7, Resident 30, and Resident 84 not being sufficiently informed of their potential financial responsibility or their right to appeal termination of Medicare Part A (insurance that covers skilled services like physical therapy) in an acceptable amount of time. Findings: During a review of the clinical record for Resident 7, the documented titled Facesheet, indicated an admission date of 4/26/19, with a history of chronic stage 5 kidney disease (long term, severe kidney damage). Review of the document titled, NOMNC no date, indicated Medicare Part A coverage end date of 5/16/19. The NOMNC, did…
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 · E2019-10-04 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
2. Review of clinical record titled Minimum Data Set (MDS, a resident assessment tool), for Resident 82, dated 9/23/19, indicated a Brief Interview for Mental Status (BIMS, a brief assessment to help detect cognitive impairment) score of 15 indicating resident is cognitively intact. Resident 82 had diagnoses that included type 2 diabetes mellitus (high blood sugar), cellulitis (a common and potentially serious bacterial skin infection of left upper limb) and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms). Review of the clinical record for Resident 82, the document titled, Order Summary Report, dated 10/1/19, indicated, Insulin Aspart Solution inject as per sliding scale: if 0 69=0 initiate hypoglycemia protocol; 70 130=0;131 180=4; 181 240=8; 241 300=10;301 350;12; 351 400=16; 401 500=20 given insulin and call MD . Review of the clinical record for Resident 82, the Medication Administration Record (MAR) dated 10/2/19, blood sugar was recorded as 223 (mg/dl) at 11:30 AM. The Insulin unit dose to be injected to Resident 82 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.
- Potential for harm · Ecited before2019-10-04 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 a medication error rate of less than 5% when six errors were observed in 25 opportunities which resulted in a 24% medication error rate. The errors were as follows: 1. Cilostazol (medicine that prevents the formation of blood clots) was not administered according to manufacturer's specification for two of nine residents (Residents 42 and 38). 2. Sevelamer (a phosphate binder, limits absorption and decreases phosphate concentrations in the blood) was not prepared according to physician's orders for one of nine residents (Resident 7). 3. Multivitamins with minerals was not administered according to physician's orders for one of nine residents (Resident 38). 4. Hydrochlorothiazide (HCTZ - medication to decrease blood pressure) was not administered according to physician's orders for one of nine residents (Resident 38). 5. Ciprofloxacin (an antibiotic used to treat bacterial infections) eye drops was not administered per manufacturer's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-10-04 · tag F0760 — failed to prevent significant medication errors — patternEnsure 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 that residents were free of significant medication errors when two of 17 sampled residents (Resident 11 and 42) were administered insulin (a hormone that lowers the level of blood sugar) that had beyond use by date. This deficient practice had the potential to negatively affect Resident 11 and 42's health and safety and may lead to unnecessary treatment and/or hospitalization. Findings: During the Side A medication cart inspection and concurrent staff interview with Licensed Vocational Nurse (LVN) 1, on 10/3/19, at 10:10 AM, the following medications were found: - For Resident 11, Insulin Lispro (a rapid acting insulin) 100 Unit/ml Vial. The label on the medication indicated open date 8/3/19. - For Resident 42, Lantus (insulin glargine, is a man made form of a hormone,insulin) 100 unit/ml Vial. The label on the medication indicated, open date 9/2/19 and discard after 9/30/19. LVN 1 acknowledged the above findings and stated that 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 · Ecited before2019-10-04 · 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
Based on observation, interview and record review, the facility did not provide pharmaceutical services to meet the needs of residents when: 1. In Side A medication cart, the following medications were found: 1a. Seven (7) opened multi dose vials of insulin (a hormone that lowers the level of blood sugar) were stored beyond use date 1b. Four (4) opened, undated multi dose vials of insulin 1c. One (1) opened, undated multi dose insulin pen (a device that help people inject insulin. It contains a cartridge, a dial to measure dosage, and a disposable needle) 1d. Five (5) opened, undated multi dose inhalers (a portable device for administering a drug which is to be breathed in, used for relieving asthma and other bronchial or nasal congestion) 2. In Side B medication room, a box of rectal suppositories was stored with oral medications and tube feeding formulas. 3. In Side B medication refrigerator, 2 packages of rectal suppositories were stored with eye drop medications and vials of flu vaccines. This failure had the potential to increase the risk of cross contamination and medication…
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 · D2019-10-04 · 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 maintain or enhance three of 22 sampled residents' dignity and respect in full recognition of their individuality when Certified Nursing Assistant (CNA) 1 stood over them as she assisted with their meals. This failure prevented the residents from exercising their right to have a dignified existence, and quality of care. Findings: During dining observation on 10/1/19 at 12:45 PM in the hallway of Unit 2, Residents 1, 32, and 57 were being fed by CNA 1. CNA 1 was standing over the residents while assisting them with their meals. During an interview with CNA 1 on 10/1/19 at 1 PM, CNA 1 acknowledged standing over the residents while assisting with their meals and stated, I have 7-8 patients, I am assigned here once a week .yes, we have in service training .my explanation is . (no words). During an interview with the Director of Nursing (DON) on 10/1/19 at 1:04 PM, DON acknowledged the finding and stated, .they should know that (they cannot stand while they feed the residents). During an interview with the DSD 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 · D2019-10-04 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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's Interdisciplinary Team failed to complete an assessment to determine the appropriateness to self-administer medication for one of one sampled resident (Resident 485) when one bottle of fluticasone nasal spray (medication used for relief of allergic nasal symptoms) and a tube of desonide cream (medication used for relief of itchiness) were found at Resident 485's bedside table. This failure had the potential for Resident 485 to overuse the medications which can lead to untoward effects and for Resident 485 to feel inadequate. Findings: Resident 485 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD, lung disease), Parkinson's disease (brain disorder that leads to shaking, stiffness, and difficulty with walking and balance) and major depressive disorder (excessive feeling of sadness and hopelessness). The Minimum Data Set (MDS, an assessment tool) indicated a Brief Interview of Mental Status (BIMS, a brief…
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 · D2019-10-04 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 two of 22 sampled residents (Residents 15 and 7) received appropriate treatment and services to maintain and improve range of motion (ROM) when the physician's order for Restorative Nursing Assistant (RNA) program was not implemented. This deficient practice had the potential for Residents 15 and 7, to experience reduction in range of motion. Findings: - Review of the clinical record titled Minimum Data Set (MDS, a resident assessment tool), for Resident 15, dated 7/8/19, indicated Resident 15 was cognitively intact. The MDS also indicated Resident 15 had impairment on both lower extremities and required assistance with her activities of daily living (ADL)s. Review of the clinical record for Resident 15, the admission Record, dated 10/3/19, indicated an admission date of 6/30/17. She had diagnoses that included muscle weakness, and difficulty walking. During an observation and concurrent interview on 10/1/9, at 9:47 AM, Resident 15…
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 · D2019-10-04 · 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
Based an observation, interview and record review, the facility failed to provide an environment that is free from accidents when one of 22 sampled residents (Resident 11) two upper bed rails were broken. This deficient practice had the potential for Resident 11 to have an accident, which may result in injury. Findings: During a review of clinical record titled Minimum Data Set (MDS, a resident assessment tool), for Resident 11, dated 7/5/19, it indicated a Brief Interview for Mental Status (BIMS, a brief assessment to help detect cognitive impairment) score of 6, indicating Resident 11 had severely impaired cognition. The MDS also indicated Resident 11 required extensive two person assist with transfers. During review of clinical record for Resident 11, the admission Record, dated 10/3/19, indicated diagnoses that included dementia (group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), history of falling and weakness. During an observation and concurrent interview on 10/1/19, 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.
- Potential for harm · D2019-10-04 · 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 ensure accurate medical record for one of 22 sampled residents (Resident 82) when licensed staff did not sign and document in the Medication Administration Record (MAR) on eight (8) medication administration opportunities and one (1) blood sugar check reading. This failure had the potential to result in improper communication between licensed nurses that may adversely affect potential medication error. Findings: Resident 82 was admitted on [DATE] and re admitted on [DATE] with diagnoses including diabetes mellitus (high blood sugar), cellulitis (a common and potentially serious bacterial skin infection of left upper limb) and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms). During a review of the September to October 2019, Medication Administration Record (MAR), for Resident 82, it indicated: 1) Insulin Glargine solution (Lantus - a long acting insulin used to improve blood sugar levels) 50 units…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to PACS GROUP — 274 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.9 | +2.1 vs chain |
| Health inspection | 5 of 5 | 2.5 | +2.5 vs chain |
| Staffing | 3 of 5 | 2.5 | +0.5 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PROVIDENCE GROUP INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2019 |
| PORTIER, DAVID | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 09/01/2019 |
| RUSSELL, MATTHEW | Individual | W-2 MANAGING EMPLOYEE | — | since 09/01/2023 |
| APT, FREDERICK | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| JERGENSEN, JOSHUA | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| MITCHELL, JOHN | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
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.
This home reported $1.1M 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 055280. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-20, 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.