Laguna Honda Hospital & Rehabilitation Ctr D/P SNF

Location & what’s nearby

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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

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.

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.

Met the expected recovery: 22.0% 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 100 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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.

Staffing

How full it usually is: this home is certified for 769 beds and averages 590.3 residents a day — about 77% occupied, or roughly 179 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 5.83 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.08 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.97 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.54 hrs/resident/day on weekends vs 6.36 on weekdays — 29% thinner on weekends — a notable drop. RN hours go from 2.44 to 1.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 17% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

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

40 citations, most serious first. The 16 most serious are shown; the remaining 24 are one tap away and print in full.

• Actual harm · Gcited before2025-08-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to protect residents' rights to be free from physical abuse by a resident for one of three sampled residents (Resident 11) when Resident 12 struck Resident 11 on the left side of her face. This failure resulted in Resident 11 sustaining a left Zygomatic Arch (cheek bone area) fracture , Left Orbital (bone area around eye) wall fracture, and contusion (swelling) on the left side of her face. Findings: A record review of Resident 11's History and Physical (H & P, an assessment completed by a medical provider) dated 5/7/25 indicated, Resident 11 was admitted with multiple diagnoses including Vascular dementia (A usually progressive condition marked by the development of multiple cognitive deficits with abrupt or gradual onset that is caused by cerebrovascular disease), Dementia related behaviors, Cerebrovascular Accident (Stroke) in 2016, history of Panic Attacks (a sudden feeling or episode of panic), history of Possible Anxiety Disorder (any of various disorders in which anxiety is a predominant feature).During a…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from sexual abuse when Resident 2 climbed into Resident 1's bed and kissed him on the lips. This failure resulted in Resident 1 not being able to sleep well due to feeling unsafe at the facility. Findings: A review of the facility policy titled ABUSE AND NEGLECT PREVENTION, IDENTIFICATION, INVESTIGATION, PROTECTION, REPORTING AND RESPONSE, last revised on 11/14/23, indicated that sexual abuse is defined as non-consensual sexual contact of any type with a resident. One of the stated purposes of the policy is to provide clinical interventions to prevent and minimize abuse or neglect . The policy further indicated that In cases of allegations of abuse . or resident-to-resident or visitor-to-resident altercation, the nurse manager or charge nurse, with input from the RCT [Resident Care Team, a collaborative group of people involved in a resident's care] and the resident(s) themselves (If possible) shall…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-04-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to protect one of one sampled Resident (Resident 1) from abuse when Resident 1 was verbally abused by a Security Guard (SG). The facility's failure resulted in Resident 1 1. thinking and reliving the incident, 2. feeling sad 3. having low self-esteem 4. having no self-respect Findings: Resident 1 was admitted with multiple diagnoses including paraplegia (loss of inability to move the legs) and chronic pain (long-term pain). Review of Resident 1's record, titled Minimum Data Set (MDS is a standard assessment tool), dated 12/1/24, indicated his memory, reasoning abilities were intact. This was reflected in his Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive function [includes thinking, learning, and decision-making abilities]). Resident 1 scored 15 out of 15 indicating he had no cognitive impairment. Under functional abilities, Resident 1 was dependent (helper does all the effort, the resident does none of the effort to complete activity) to requiring substantia/maximal…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-28 · 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 adequate supervision for one of four sampled residents (Resident 1) when Resident 1 was ambulating (walking) in the facility independently without any assistive devices (objects used to help stabilize someone for safer movement). This failure resulted in Resident 1 sustaining a left femoral neck fracture (a break in the long upper leg bone near where it touches the hip bone) requiring a left hemiarthroplasty (surgery necessary to replace part of the hip joint). Findings: A review of a Resident 1's Quarterly Minimum Data Set (MDS, a resident assessment tool), dated 12/29/23, indicated that Resident 1 has multiple diagnoses including Alzheimer's disease (a brain disorder that slowly impairs memory and thinking skills) and a history of a subarachnoid hemorrhage (bleeding in the space around the brain). The MDS also indicated that the staff assessment for mental status was done for Resident 1 and her Cognitive skills [brain functions] for daily…

  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
• Actual harm · Gcited before2024-02-09 · 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 ensure Resident 1's fall care plan interventions were updated and implemented to prevent or minimize fall-related injuries for one of 20 sampled residents (Resident 1) when Resident 1 was assessed as total dependent with activities of daily living, including repositioning when in bed. The care plan interventions did not reflect the two person physical assist required by Resident 1 when repositioning and the facility did not implement effective interventions to prevent falls after identifying Resident 1 with limited Range of Motion (ROM) on bilateral upper and lower extremities, diagnosis of Seizure Disorder (a medical condition that can cause sudden, uncontrollable movements and change in level of consciousness) and poor safety awareness due to diagnosis of Dementia (impaired ability to remember, think, or make decisions). This failure resulted in Resident 1 to have an avoidable fall from her bed during personal care by Patient Care Assistant (PCA) 1…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of twenty sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice, comprehensive person-centered care plan to enable residents to maintain their highest practicable level when Resident 1 who was assessed as a high risk for fall, total dependent with activities of daily living, including repositioning when in bed sustained a fall on [DATE]. The care plan interventions did not reflect the two person physical assist required by Resident 1 when repositioning and the facility did not implement effective interventions to prevent falls after identifying Resident 1 with limited Range of Motion (ROM) on bilateral upper and lower extremities, diagnosis of Seizure Disorder (a medical condition that can cause sudden, uncontrollable movements and change in level of consciousness) and poor safety awareness due to diagnosis of Dementia (impaired ability to remember, think, or make decisions). This…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-23 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  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 that one out of two sampled residents (Resident 1) had a safe and clean environment. This deficient practice resulted in placing Resident 1 at risk for accidents and unsafe conditions.During a review of MD Assessment for Resident 1, dated 02/27/2026, the MD Assessment indicated Resident 1 has the following active diagnoses that requires a clean, safe and hazard-free environment that is calm and predictable for Resident 1: blindness, schizoaffective disorder, bipolar type, and human immunodeficiency virus (HIV) infection.During an observation conducted on 04/22/2026 at 2:47 PM, Resident 1's room was found to be cluttered with excessive items stored on surfaces, furniture, and the floor.The bedside table to the left of Resident 1's bed was completely covered with numerous items, including but not limited to two dented cans of pineapple juice, multiple spray bottles, seven bottles of lotion, clothing items, plastic food containers, mouthwash, used paper and medication cups, an opened shipping package, a…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-04 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to report four allegations of abuse, within two hours, to the California Department of Public Health (the Department). This failure had the potential to leave residents vulnerable to further abuse. Findings: A review of Form SOC 341 Report of Suspected Dependent Adult/Elder Abuse, dated 5/27/25, submitted by the facility to the Department on 5/27/25, at 17:53, indicated Residents 1 and 2 had been involved in a resident-to-resident sexual abuse. The report indicated Resident 2 was standing at bedside of Resident 1. Resident 2 attempting to open Resident 1's brief with his right hand, his left hand in his pants. When redirected, Resident 2 became physically aggressive towards the staff. The incident happened on 5/25/25 at 12:30 AM. Review of Resident 1's admission record, indicated, Resident 1 had a had stroke, with right sided weakness, Dysphagia, (difficulty swallowing), Aphasia, (difficulty with talking) and Neurocognitive disorder. Has a BIMS (Brief Interview for Mental Status) score of 0, daughter is decisionmaker. Review…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-05-02 · tag F0814 — failed to dispose of garbage properly — widespread
  Dispose of garbage and refuse properly.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and facility document review, the facility failed to ensure one, full, outside refuse (garbage) container lid was closed, and that outside recycle and compost bins were cleaned. This failure had the potential to attract pests such as rodents and insects resulting in the spread of disease to all residents for a facility census of 506. Findings: During a concurrent observation and interview with Food Service Director (FSD) on 4/29/25 at 10:21 AM, showed two black garbage bins stored against a building across from the kitchen loading dock area. One garbage bin was filled to the top and the lid was open. Contents of the open garbage bin included used food containers. During a concurrent observation outside behind the kitchen across from the loading dock area and interview on 4/30/25 at 10:21 AM, the Director of Emergency Management (DEM) confirmed the full garbage bin lid was opened and stated the lid should be closed. During a concurrent observation and interview on 4/30/25 at 10:23 AM, with DEM and the Executive Director of Facility Services (EDFS),…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-05-02 · tag F0925 — failed to control pests — widespread
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and facility document review, the facility failed to ensure the kitchen was free from flies. The failure to ensure the kitchen was free from flies had the potential to contaminate food, equipment, and utensils and result in pest transmitted disease for 467 residents who received food from the kitchen out of a census of 506. Findings: An observation during the initial tour of the kitchen on 4/28/25 at 9:12 AM, showed small flies were on the ceiling and walls in the dish machine room, mainly around the area where bins were located for items such as shredded paper, refuse, and recycling. An observation and interview in the kitchen on 4/29/25 at 10:00 AM., showed at least 15 small flies on the ceiling above refuse, recycling bin area. In addition, there were also at least four flies on the ceiling in the food production/trayline area. The Food Service Director (FSD) confirmed there were flies on the ceiling and stated he was not aware of the flies in the kitchen. FSD stated the pest company serviced the kitchen three times a week. FSD stated if staff…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-02 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to ensure resident rights to choose treatment options was honored for one of three residents (Resident 290) when, urine sample was sent for urine toxicology (also known as drug screen, a test that analyzes a urine sample to detect the presence of drugs or other chemicals) and completed on 4/16/25, which the resident refused. This deficient practice violated residents' rights to make medical decisions. Findings: Record review of Resident 290's Face Sheet, dated 5/1/25 indicated, Resident 290 was admitted to the facility on [DATE] at 11:30 AM. Record review of Resident 290's BIMS (Brief Interview for Mental Status - an assessment tool used to screen cognitive impairment), dated 2/1/25 indicated, a score of 15 (cognitively intact). Record review of Resident 290's Physician Progress Notes, dated 4/18/25 indicated, diagnoses including, quadriplegia (medical condition characterized by the partial or total loss of function in all four limbs and 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 · D2025-05-02 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  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 appropriately administer medication when one of 35 sampled residents (Resident 414) was self-administering medication without being appropriately assessed and approved for self-administration. This failure had the potential for Resident 414 to aspirate (choking, the accidental inhalation of food, liquid, or other material into the lungs) from improperly administered medication. Findings: Review of Resident 414's History and Physical (H&P), dated 6/8/22, indicated Resident 414 had diagnoses including impaired mobility, impaired activities of daily living, left hemiparesis (weakness or the inability to move on one side of the body) and dysphagia (difficulty of swallowing). During a concurrent observation and interview on 4/29/25 at 11:02 AM with Resident 414, a half full cup of thick, dark orange colored liquid was seen on top of Resident 414's bedside table. Resident 414 drank it and stated, It's orange juice that tastes like Metamucil (a medication for constipation), when asked what it was. During an…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-02 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the baseline care plan was developed within 48 hours of admission for one of 35 sampled residents (Resident 879) on ADL (Activities of Daily Living) for oral care. This failure had the potential to result in inadequate care and services rendered to Resident 879. Findings: Review of Resident 879 admission record indicated, Resident 879 was admitted on [DATE] , indicated during admission, diagnoses including Stroke, Dysphagia (trouble swallowing), Heart Failure, Aphasia (unable to speak), Systemic lupus erythematosus (a chronic condition where the body's immune system attacks its own tissues). During an interview on 04/30/25 at 9:48 AM with Nurse Manager 2 (NM 2). NM 2 stated baseline assessment is usually done during admission and within 48 hours. NM 2 confirmed baseline care plan was not developed within 48 hours after admission. During an interview on 04/30/25 9:50 AM with Patient Care Assistant1 (PCA 1), PCA 1 stated for a new admit resident…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-02 · 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 observations, interviews, and record reviews, the facility failed to meet professional standards of quality when: 1.One out of two sampled residents (Resident 183) received oxygen therapy outside the prescriber's order. This failure could potentially result in negative outcomes for Resident 183 like shortness of breath, fatigue and confusion. 2.Two residents out of 42 sampled residents reviewed for medication administration (Resident 44 and Resident 155) received medication outside the prescriber's order and parameters. These failures resulted in Resident 44 receiving prescription medication Glipizide (a medication to treat high blood sugar) 10 mg tablet for type 2 diabetes mellitus (high blood sugar) outside prescribing parameters and Resident 155 receiving incorrect application of Lidocaine 5% patch for pain outside the prescriber's order. These failures have the potential for Resident 183, Resident 44, and Resident 155 to receive inadequate care. Findings: 1.Review of Resident 183's MDS (minimum data…

  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 · D2025-05-02 · 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 accurately dispose of and record disposal of controlled drugs for one of one sampled resident reviewed for safe and secure disposal and recording methods for controlled medications (Resident 332). This failure could result in Resident 332 receiving an inaccurate dose or diversion of the controlled medication. Findings: During an observation of Medication Room on 04/30/2025 at 10:31 AM revealed an Omnicell receipt dated 04/30/2025 with time 10:03 AM for Methadone Concentrate 50 mg/ 5mL Cup, with the names of RN3 and RN4 noted on the receipt for Resident 332, and with an administration amount noted as 90 mg and a waste amount noted as 10 mg. Methadone is classified as a Schedule II controlled substance, which means it is recognized for its medical use but has a high potential for abuse and addiction. This classification indicates that even though methadone can be prescribed for certain conditions, such as for pain management, it must be…

  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 · D2025-05-02 · tag F0802 — failed to prepare enough nourishing food — isolated
  Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and facility document review, the facility failed to ensure that one out of one kitchen staff was competent when testing sanitizer (a substance or product that reduces or eliminates microorganisms such as bacteria on surfaces to a safe level) strength used to sanitize food contact surfaces. This failure had the potential to result in compromising infection control and resident safety. Findings: During an observation and interview on 4/28/25 at 1:45 PM with Food Service Supervisor (FSS)1, FSS1 stated he was responsible for testing the sanitizer strength for the sanitizer used in the red buckets (sanitizer used to test food contact surfaces). FSS1 demonstrated how he tested the sanitizer strength. FSS1 held a sanitizer test strip in the sanitizer solution inside a red bucket for 20-21 seconds then immediately compared the color of the strip to the color chart on the test strip packaging to determine the concentration. When FSS1 was asked how many seconds the test strip was to be held in the solution, FSS1 stated for about 10 seconds. Review of 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.

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

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

Fines & penalties

$55,499 in federal fines across 8 penalties.

• $17,323 — penalty dated 2025-08-01
• $4,938 — penalty dated 2024-02-20
• $4,938 — penalty dated 2024-02-12
• $12,534 — penalty dated 2024-01-22
• $3,418 — penalty dated 2024-01-08
• $2,823 — penalty dated 2024-01-02
• $6,351 — penalty dated 2023-12-11
• $3,174 — penalty dated 2023-11-06

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

CMS files one row per role, so the 15 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

What families pay in CA