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San Francisco Post Acute

5767 Mission Street, San Francisco, CA 94112 · For profit - Limited Liability company · 53 certified beds · (415) 584-3294 Medicare & Medicaid certified

Call the home — (415) 584-3294 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)

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

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

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
164 Treeview Dr · (814) 237-4321 · Call to confirm hours
Pharmacy
Walgreens0.5 mi
6100 Mission St · (650) 992-3900 · Call to confirm hours
Grocery
601 Brunswick St · (415) 333-1640 · Call to confirm hours
Park
670 Brunswick St · (415) 831-2700 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.6%10.2%15.4%better
Long-stay residents who lose too much weight2.6%4.0%5.4%better
Long-stay residents with a catheter left in their bladder1.3%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms2.6%7.3%6.5%better
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened3.8%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication3.8%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers0.0%4.3%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control8.4%10.2%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table1.6%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission29.8%23.0%22.6%worse
Short-stay residents with an outpatient ER visit18.0%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.812.251.67typical
Long-stay outpatient ER visits per 1,000 resident days1.511.571.80better

* 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.

61.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 259 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.0%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
89.0%U.S. median 56.6%
Met the expected recovery
0.98U.S. median 0.31
Therapy hours / resident / day
0.48hours / resident / day
Physical therapy
0.34hours / resident / day
Occupational therapy
0.16hours / resident / day
Speech therapy

Met the expected recovery: 89.0% 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 118 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 0.98 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF61.0%CMS range 55.5–67.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.5–12.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge89.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge73.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge63.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge93.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 3.9–9.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.351.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.56
RN hours/ resident / day
1.26
LPN hours/ resident / day
2.53
Aide hours/ resident / day
4.35
Total nurse hours/ resident / day
0.49
RN hoursweekends
35.5%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 53 beds and averages 48.8 residents a day — about 92% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.35 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.98 hrs/resident/day on weekends vs 4.50 on weekdays — 12% thinner on weekends. RN hours go from 0.59 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% 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

5
deficiencies at the latest standard inspection (2024-12-12)
14
at the previous standard inspection (2023-10-06)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · E2024-12-12 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow disinfection protocols for reusable items which includes durable medical equipment (DME - equipment that is used for a medical purpose, is used in the home, and is expected to last at least three years) for three out of three residents (Residents 18, 29, and 41). This failure puts residents at risk for cross contamination and the possible spread of infection among residents. Findings: During a continuous observation on 12/8/24 from 8:55 a.m. to 9:25 a.m. on unit B, with Registered Nurse 1, (RN1) was observed taking Resident 29's blood pressure, then Resident 41's blood pressure, and finally Resident 18's blood pressure. Each time, RN1 did not disinfect the blood pressure cuff prior to taking the residents' blood pressures. During an interview on 12/09/24 at 1:50 p.m., with RN1, she was unclear about the facility's policy and procedure (P&P) regarding disinfecting resident care equipment, and offered no explanation. RN1 stated she would have to check with the Director of Nursing (DON) & check the P&P.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-12 · 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

    Based on observation, interview and record review, the facility failed to implement pain care plan for 1 of 14 sampled residents (Resident 38) when there was no evidence of pain assessment. This failure had the potential for not meeting Resident 38's nursing needs and goals to attain the resident's highest practicable well-being. Findings: Review of Resident 38's clinical record indicated, Resident 38 was admitted to the facility with diagnoses including displaced intertrochanteric fracture of left femur (broken left thigh bone), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and hyperlipidemia (high cholesterol). Review of Resident 38's Minimum Data Set (MDS, resident assessment tool) dated 10/2/24 indicated, Resident 38 was cognitively intact. During a concurrent observation and interview on 12/8/24 at 12:09 p.m., with Resident 38 in front of his room in hallway, he pointed to his abdomen while speaking in Chinese when asked if he had a pain. During a concurrent interview and record review 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-12 · 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

    Based on observation, interview and record review, the facility failed to meet professional standards of quality when the facility did not follow doctor's order regarding oxygen for one of 2 sampled residents (Resident 8). This failure could potentially result in negative outcomes for Resident 8. Findings: Review of Resident 8's clinical record indicated, Resident 8 was admitted to the facility with diagnoses including spinal stenosis (the spaces inside the bones of the spine get too small), acute respiratory failure with hypoxia (a serious medical condition that occurs when there is not enough oxygen in the body's tissues), chronic obstructive pulmonary disease (COPD, a lung disease that makes breathing hard), and hypertension (high blood pressure). Review of Resident 8's Minimum Data Set (MDS, resident assessment tool) dated 11/16/24 indicated, Resident 8 was cognitively moderately impaired. Review of Resident 8's H&P (history and physical, a formal assessment of a resident that includes a review of their medical history, a physical exam, and a summary of any tests) dated 11/14/24…

    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 · D2024-12-12 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 communication services were provided for one of 6 sampled residents (Resident 38) who spoke in his native language when there were no interpreter services for Resident 38 on Sunday (12/8/24). This failure has the potential for Resident 38 not to understand and carry out activities of daily living (ADL) to attain the resident's highest practicable well-being. Findings: Review of Resident 38's clinical record indicated, Resident 38 was admitted to the facility with diagnoses including displaced intertrochanteric fracture of left femur (broken left thigh bone), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and hyperlipidemia (high cholesterol). Review of Resident 38's Minimum Data Set (MDS, resident assessment tool) dated 10/2/24 indicated, Resident 38 was cognitively intact. During an interview on 12/8/24 at 11:58 a.m., with Son of Resident 38 via phone, Son stated, Resident 38 speaks Cantonese, Mandarin, and Chinese…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure Resident 25 was free from unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic [a type of psychiatric medication which are available on prescription to treat psychosis]; (ii) Anti-depressant [prescription medicines to treat depression]; (iii) Anti-anxiety [drugs used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress]; and (iv) Hypnotic [a class of drugs that induce or prolong sleep in people with sleep disorders and are intended to improve the overall quality of sleep]) when: 1.There was no evidence of non-pharmacological intervention for Aripiprazole (antipsychotic), Bupropion (antidepressant), Lorazepam (antianxiety), and Mirtazapine (antidepressant) for Resident 25 2. There was no targeted behavior of Lorazepam for Resident 25. 3. There was no evidence of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-28 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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, one of three sampled residents (Resident 1), Resident 1's representative with the 7-Day Bed-hold written notice at the time of transfer or within 24 hours of Resident 1's emergency transfer to a higher level of care on [DATE]. This failure resulted in a facility-initiated discharge on [DATE] for Resident 1. Findings: During a review of Resident 1's Summary for Providers, the Summary indicated that Resident 1 had an emergency transfer to the hospital on [DATE], due to a change of condition (COC). During a review of Resident 1's face sheet (FS), the FS indicated that Resident 1 was admitted to the facility on [DATE] and discharged on [DATE] (7 days after an emergency transfer due to a COC). During a concurrent interview and record review on [DATE] at 4:20 PM with Executive Assistant (EA), the EA was unable to locate documented evidence to show Resident 1's representative was provided with the 7-Day Bed-hold written notice at the time of transfer…

    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 · F2023-10-06 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    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 have a full-time, qualified, and competent person to supervise food and nutrition services when: 1. The registered dietitian (RD) and the qualified dietary supervisor were at the facility less than full-time defined as 35 hours per week; 2. Food and Nutrition Services (FNS) supervisory staff did not ensure: a resident received food preferences; FNS staff were competent to carry out job duties and tasks they performed; the planned menu was followed; a resident received the appropriate texture food according to the diet order; there was an effective system to maintain food and nutrition services in a safe and sanitary manner; and the kitchen was pest free; and 3. The dietary supervisor did not ensure chicken potstickers were cooked to an appropriate temperature. These failures had the potential to compromise the safety and nutritional status of residents through the potential transmission of foodborne illness, the provision of inadequate nutrients, the provision of food texture that did not meet…

    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 · F2023-10-06 · tag F0802 — failed to prepare enough nourishing food — widespread
    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 the competency of Food and Nutrition Staff when: 1. A cook did not know the steps for cooling Time Temperature Control for Safety (TCS, foods more likely to grow harmful bacteria and/or microorganisms if not stored appropriately) food; 2. A cook did not follow recipes when preparing food for the planned menu; 3. A diet aide did not know how long to submerge items in the sanitizer solution when washing manually using the 2-compartment sink; 4. A diet aide did not follow manufacturer's instructions for a sanitizer test strip when testing the surface sanitizer. These failures had the potential to compromise the safety and nutritional status of residents through the transmission of foodborne illness and the provision of inadequate nutrients and/or decreased quality of food for 51 residents who received food from the kitchen out of a census of 51. Findings: 1. Review of the Cooldown Temperature Log dated October 2023, showed instructions which read Food must be cooled from 140 degrees Fahrenheit…

    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 · F2023-10-06 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 follow the planned menu when: 1) The incorrect serving size of the main entrée was served according to the menu for a lunch meal; 2) Pureed melon was not served according to the menu for a lunch meal. 3) Pureed salad was not served according to the menu for a lunch meal. 4 ) Fresh strawberry and ice cream were not served according to the menu for a lunch meal. This failure to follow the planned menu had the potential to result in residents not receiving the nutrients the menu was intended to provide leading to decreased nutrient intake and further compromising residents' medical status for 51 residents who received food from the kitchen. Findings: Review of the policy and procedure titled Menus revised October 2017, showed menus are developed and prepared following established national guidelines for nutritional adequacy. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board. The dietitian reviews and approves all menus. Menus…

    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 before2023-10-06 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure food safety requirements in accordance with professional standards for food service safety when: 1. Staff did not ensure food was cooled safely. 2. Pans and bowls were not dried appropriately. 3. Frying pans were in poor condition. 4. A large mixer was not clean and in poor condition. 5. An industrial can opener was not clean and in poor condition. 6. Refrigerator and Freezer door rubber gaskets (a rubber strip surrounding the perimeter of the inside of the cooler door to seal the door when it is closed so air cannot go in or out) were not clean. 7. Staff did not handle clean dishes appropriately to prevent contamination of the dishes. 8. There was no airgap (a gap between the sink drains and the drain that leads to sewage drain. This gap prevents a back-up of non-potable water and/or bacteria into the sink) for the food preparation sink drain. 9. Nursing staff who monitored food refrigerator temperatures did not know appropriate refrigerator temperatures to store food safely. 10. Refrigerated food…

    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
Show the remaining 14 citations
  • Potential for harm · F2023-10-06 · 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 maintain the outside compost bin in a clean manner. This failure had the potential to attract pests resulting in pest related illness for 51 residents out of a census of 51. Findings: An observation and interview with Dietary Supervisor 2 (DS2) on 10/3/23 at 12:51 p.m., showed a compost bin stored outside with other waste receptacles directly next to the facility's outside side wall. The compost bin had a significant amount of thick dark brown and black residue on the outside surface and sides of the inside surface of the bin also covered with a thick black and brown residue. DS2 stated the black and brown residue was food residue. In an interview on 10/3/23 at 2:54 p.m., the maintenance supervisor confirmed the outside compost bin was dirty. Review of the document titled Miscellaneous Areas dated 2020, showed each time the garbage is emptied, containers must be cleaned thoroughly. In addition, the trash collection area is a potential feeding ground for vermin and rodents and must be clean.…

    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 · F2023-10-06 · 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 maintain the kitchen free of pests. This failure had the potential to result in contamination of food and utensils used by residents leading to pest related disease and/or illness for 51 residents who received food from the kitchen out of a facility census of 51. Findings: An observation and concurrent interview with Dietary Supervisor 1 (DS1), Dietary Supervisor 2 (DS2), and the Maintenance Supervisor (MS) on 10/2/23 at 9:50 a.m., showed a small fly on the wall above the food preparation sink and adjacent to the knife storage area on the wall. Below the food preparation sink was an open cabinet where the sink drain was plumbed into the wall. There were more than 30 alive flies in inside the cabinet space. In addition, two long pieces of sticky tape over four inches in length and 1.5 inches wide were in the cabinet space and were covered with dead flies stuck to the tape. DS1 and DS2 stated they were not aware of the flies. MS stated the flies were not reported to him. In a phone interview with the…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-06 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan (CP) for each resident that included measurable objectives and specific interventions for four of 13 sampled residents (Residents 18, 19, 43, and 31) when: 1. The CP for Resident 19 did not have specific interventions for the use of Trazodone (medication used to treat depression). 2. No individualized person-centered CP was developed for the management of peripherally inserted central catheter (PICC - a long thin tube that's inserted through a vein in an arm and passed through a larger vein near the heart) line for Residents 18 and 43. 3. No individualized person-centered CP was developed for the management of the urinary catheter (a tube left in the bladder to carry urine from the bladder to outside the body) for Resident 43. 4. No individualized person-centered CP was developed for the use of oxygen for Resident 43. 5. No individualized person-centered CP was developed for Resident 31 to include her lack of teeth and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-06 · tag F0806 — failed to honor food preferences — pattern
    Ensure 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 facility document review, the facility failed to: 1. Provide food preferences to one resident (Resident 10); and 2. Provide an appealing option of similar nutritive value for milk when 39 residents chose not to drink milk. These failures had the potential for residents to not receive the amount of nutrients provided by the planned menu and/or the Registered Dietitians recommended nutrient needs leading to nutrient deficiency, weight loss, and/or malnutrition out of a census of 51. Findings: 1. A record review for Resident 10 showed he was originally admitted to the facility on [DATE] with diagnoses including but not limited to congestive heart failure ((a chronic condition in which the heart does not pump blood as well as it should), chronic kidney disease stage 3 (when kidneys have mild to moderate damage, and are less able to filter waste and fluid out of the blood), severe obesity, depression, and pulmonary edema. The MDS (Minimum Data Set, an assessment tool) dated…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-06 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care and services provided meet professional standards for one of 13 sampled residents (Resident 43) when there was no order for the use of oxygen for Resident 43. This failure could potentially prevent staff from providing Resident 43 with appropriate treatment and care which could jeopardize the resident's health and safety. Findings: Resident 43 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - lung disease that cause airflow blockage and breathing related problems), and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred, as it worsens, become progressively more short of breath). During a concurrent observation and interview on 10/2/23 at 11:00 AM with Resident 43 in the resident's room, Resident 43 was on oxygen at 2L/min (liters/minute) via nasal cannula (device that delivers extra oxygen through a tube and into the nose that help people who are…

    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 before2023-10-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident's (Resident 10) nutritional status was maintained when poor intake, significant weight loss, and insidious weight loss were not monitored and assessed. This failure had the potential to result in avoidable weight loss from inadequate nutrient intake for one resident out of a facility census of 51. Findings: A professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014 showed, Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-06 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the manufacturer's recommendations and specifications for installing and maintaining bed rails when the bed of Resident 10, one of 13 sampled residents, had a left sided bed rail that would fall down periodically when used by resident. This failure of the facility had the potential to injure the resident resulting from an accidental fall from the bed. Findings: Resident 10 was admitted to the facility on [DATE] with diagnoses including, ulcers of both lower extremity's (legs), severe obesity (excessive body fat), depression and anxiety, gait (walking disorder) and mobility abnormalities, kidney failure, pulmonary edema (accumulation of liquid in lungs), congestive heart failure (inability of heart to pump sufficient blood flow), and generalized muscle weakness. Resident 10's Minimum Data Set (MDS, an assessment tool) indicated moderately impaired cognition (thinking), required two staff assist to turn and reposition in bed, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-06 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe storage and proper labeling of medication when an unlabeled loose white round tablet and cherry colored liquid were found on Resident 19's over bed table. This deficient practice had the potential for Resident 19 to self-administer or receive incorrect medication that may cause harm or death, and the unattended medication had the potential for drug diversion. Findings: Resident 19 was admitted on [DATE] with diagnoses including alcoholic cirrhosis of liver with ascites (chronic liver damage from a variety of causes leading to scarring and liver failure with buildup of fluid in the abdomen) and traumatic brain injury (brain dysfunction caused by an outside force usually by a violent blow to the head). During a concurrent observation and interview on 10/2/23 at 9:32 AM with Resident 19 in the resident's room, there was an unlabeled loose white round tablet in a medication cup and another medication cup filled with cherry colored…

    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 · Dcited before2023-10-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 13 sampled residents (Resident 19) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when Resident 19 received Trazodone (an antidepressant) without adequate monitoring. This failure had the potential for Resident 19 to receive unnecessary psychotropic medication and be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being. Findings: Resident 19 was admitted on [DATE] with diagnoses including alcoholic cirrhosis of liver with ascites (chronic liver damage from a variety of causes leading to scarring and liver failure with buildup of fluid in the abdomen), traumatic brain injury (brain dysfunction caused by an outside force usually by a violent blow to the head), and major depressive disorder. During a review of Resident 19's Order Summary Report (OSR), the OSR…

    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 · D2023-10-06 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 Resident 31 was served the correct food texture according to her physician prescribed therapeutic diet. This failure to serve Resident 31 the prescribed texture of food had the potential to result in one resident not being able to tolerate food texture resulting in decreased nutritional intake and/or choking. Findings: Review of Resident 31 face sheet indicated, Resident 31 was admitted with diagnoses of: dysphagia (a medical term for swallowing difficulties), muscle weakness, and lack of coordination. Her brief interview for mental status (BIMS - an evaluation tool to test cognitive skills) was 8 indicating moderate cognitive impairment. During meal observation on 10/4/23 at 12:09 p.m., in the dining room, observed Resident 31 quietly eating her lunch. On her plate was noodles with pieces of meat that resembled chicken, and green and yellow chopped vegetables. The pieces of meat were varied in length between two to three inches long. Resident 31 moved her food around her plate with her eating utensil.…

    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 · E2021-10-14 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store medications according to standard of practice when: 1. Two injection needles with damaged packaging, 12 expired syringes of saline (a mixture of salt and water) and a box containing 100 expired syringes were kept in the medication room. 2. Three opened insulin (medication that allows your body to use sugar) vials and three opened and used insulin vials after 28 days were kept inside the medication cart. These failures had the potential to subject residents to sub-therapeutic medications, non-sterile needles, and use of expired syringes. Findings: During medication room observation on [DATE] at 9:01 AM, with the Director of Nursing (DON), the following were found: a. Two sterile injection needles had damaged packaging. Their paper backing had two small linear tears (approximately 1/4 inch long); b. Twelve syringes of saline dated [DATE] and c. A box containing 100 syringes with expiration date of 11/2019. During medication cart…

    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 · E2021-10-14 · tag F0808 — failed to follow doctor-ordered diets — pattern
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure the Physician ordered therapeutic diet was followed for four of four residents on renal diet (Resident 153, 22, 27 and 11). The deficient practice had the potential to compromise the health of the residents on therapeutic diets. Findings: Review of the facility document titled Diet Type Report dated 10/13/21, indicated, Resident 153, 22, 27 and 11 had a physician ordered renal diet. During dining observation and concurrent interview on 10/13/21, at 12:45 PM, Resident 11's meal ticket indicated, Regular, Consistent Carbohydrate Diet (CCHO), Renal, small portions, thin liquids. Resident 11's meal tray consisted of tandoori chicken with tandoori sauce, rice and zucchini. Resident 11 stated, she never liked sauce on her food because it made her food sweeter. During an interview on 10/13/21, at 2 PM, DC 1 was asked how he would determine which food to plate for renal diet. DC 1 stated, therapeutic diets such as renal diet have the same food meal content as the regular diet. DC 1 stated, the only difference…

    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 · Ecited before2021-10-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure safe food practices when: 1. The water heater has build up of grease and dirt. 2. A green bucket placed on top of water heater contained sponges, a scrubber and three unidentifiable tools were kept on top of the water heater. 3. The hair of the kitchen staff was not properly restraint. These deficient practices had the potential to expose residents to food borne illness. Findings: During kitchen observation and interview with the Dietary Supervisor, on 10/12/21, at 10:15 AM, the following were observed: 1. There was noticeable buildup of grease and dirt on the top and front surfaces of the water heater located under the dishwasher's clean dish table. 2. A green bucket contained two dried sponges, one silver colored metal scrubber with embedded particles of food, and three metal tools were stored on top of the water heater. The DS verified and acknowledged the water heater surfaces needed to be cleaned. The DS stated he was not sure where to keep the green bucket containing the items mentioned. Review of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1:1 assistance during meal was provided as per physician's order and Registered Dietician's recommendation for one of 13 sampled residents (Resident 21). This deficient practice contributed to Resident 21's weight loss. Findings: Resident 21 was readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) and protein-calorie malnutrition. Review of Resident 21's quarterly Minimum Data Set (MDS-an assessment tool), dated 9/5/21, indicated, Resident 21 was cognitively impaired. Under functional status for activities of daily living (ADL) indicated Resident 21 required assistance for eating including supervision, oversight, encouragement or cueing. During a dining observation on 10/12/21 at 12:21 PM, Resident 21 was eating in her room by herself. No staff aided Resident 21 with meals. During a follow-up observation on 10/12/21, at 12:37 PM, Resident 21 has finished eating her meal. Then, the Certified 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to 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 →

RatingThis homeChain avg
Overall 5 of 52.9+2.1 vs chain
Health inspection 4 of 52.5+1.5 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 273 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Anchor Post AcuteAiken, SC 1 of 5Arbor Post AcuteChico, CA 1 of 5Artesia Palms Care CenterArtesia, CA 1 of 5Arvin Post AcuteArvin, CA 1 of 5Ashland Post AcuteAshland, OR 1 of 5Bakersfield Post AcuteBakersfield, CA 1 of 5Beachwood Post-Acute & RehabSanta Monica, CA 1 of 5Brookshire Post AcuteDenver, CO 1 of 5Brushy Creek Post AcuteGreer, SC 1 of 5Buckeye Care And RehabilitationLancaster, OH 1 of 5Carnegie Park Post AcutePittsburgh, PA 1 of 5Cascade Terrace Post AcutePortland, OR 1 of 5Centennial Post AcuteAnchorage, AK 1 of 5Chandler Creek Post AcuteGreer, SC 1 of 5Chehalem Post AcuteNewberg, OR 1 of 5Country Hills Post AcuteEl Cajon, CA 1 of 5Delhi Post-AcuteCincinnati, OH 1 of 5Dublin Post AcuteDublin, OH 1 of 5Edisto Post AcuteOrangeburg, SC 1 of 5Evan Terrace Post AcuteMcMinnville, OR 1 of 5Forest Acres Post AcuteColumbia, SC 1 of 5Grandview Post AcuteCookeville, TN 1 of 5Great Plains Post AcuteWichita, KS 1 of 5Hemet Hills Post AcuteHemet, CA 1 of 5Highland Hills Post AcutePittsburgh, PA 1 of 5Highline Post AcuteDenver, CO 1 of 5Johns Island Post AcuteJohns Island, SC 1 of 5Karcher Post AcuteNampa, ID 1 of 5Kennedy Care CenterLos Angeles, CA 1 of 5Kern River Transitional CareBakersfield, CA 1 of 5Lakeview Post AcuteFlorissant, MO 1 of 5Marion Valley Post AcuteMarion, OH 1 of 5Mirage Post AcuteLancaster, CA 1 of 5Monroeville Post AcuteMonroeville, PA 1 of 5Napa Post AcuteNapa, CA 1 of 5North Royalton Post AcuteParma, OH 1 of 5Northstar Post AcuteCarson City, NV 1 of 5Overland Park Post AcuteOverland Park, KS 1 of 5Pikes Peak Post AcuteColorado Springs, CO 1 of 5Ridgeway Post AcutePetaluma, CA

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 / managerTypeRoleShareSince
PROVIDENCE GROUP NORTH LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 06/20/2015
PORTIER, DAVIDIndividualCONTRACTED MANAGING EMPLOYEEsince 01/01/2019
SAMIA, NEILIndividualW-2 MANAGING EMPLOYEEsince 05/01/2022
APT, FREDERICKIndividualCORPORATE OFFICERsince 01/01/2024
HANCOCK, MARKIndividualCORPORATE OFFICERsince 02/10/2021
JERGENSEN, JOSHUAIndividualCORPORATE OFFICERsince 01/01/2024
MITCHELL, JOHNIndividualCORPORATE OFFICERsince 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.

$14.2M
Net patient revenuemost recent cost report
+20.8%
Operating marginrevenue minus expenses
$745K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 9%Medicare 42%Other / private 49%

This home reported $745K 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

$631per resident / day
operating cost
$19,196per month
≈ monthly operating cost
$798per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 056449. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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