The Avenues Transitional Care Center
2043 19th Avenue, San Francisco, CA 94116 · For profit - Limited Liability company · 140 certified beds · (415) 661-8787 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- it has 1 actual-harm citation
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $12,685 in federal fines (most recent 2025-10-02)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
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
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.9% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.6% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 8.0% | 7.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.0% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 6.5% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 4.1% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.3% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.0% | 10.2% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.9% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.4% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.1% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.6% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.52 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.43 | 1.57 | 1.80 | worse |
‡ 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.
55.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 235 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 72.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 117 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 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.0%CMS range 48.6–62.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 7.6–13.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 72.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 67.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 68.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 94.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.2%CMS range 3.4–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.18 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 140 beds and averages 134.5 residents a day — about 96% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.46 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 3.73 hrs/resident/day on weekends vs 4.07 on weekdays — 8% thinner on weekends. RN hours go from 1.03 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.
- Actual harm · G2025-10-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent an avoidable fall for one (Resident 1) of four sampled resident when Resident 1 fell from bed to the floor.This failure resulted in Resident1 fall with injury, hospitalization, and subsequent death. Record review of Resident1's Clinical admission Record, admission Record indicated, Resident 1 was admitted on [DATE] with diagnoses including quadriplegia (paralysis from the neck down, affecting both arms and legs, usually due to a spinal cord injury), a personal history of physical injury and trauma, and dementia (a progressive decline in mental abilities). At the time of the incident, Resident 1 was in room [ROOM NUMBER] bed A. During an observation on [DATE] at 2:05PM in room [ROOM NUMBER], there were three beds (39A, 39B and 39C). Bed A was the first bed near the door, bed with side table beside it. Both guard rails were down. The restroom is at the far end of the room, in front of bed C. During a telephone interview conducted on [DATE] at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-03-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to ensure food safety requirements in accordance with professional standards for food service when: 1. A dirty frying pan was found stacked in between clean frying pans under the food preparation counter. 2. Large metal pans and trays for serving were stacked wet under the food preparation counter. 3. A large can of mushroom was found dented among the undented canned products in the dry storage room. The failure to store clean cooking utensils, wet serving trays and dented canned products has the potential to contaminate other clean cooking utensils and promote growth of food borne illnesses to 133 residents. Findings: 1. During observation and interview with the dietary manager (DM) on 3/18/25 at 10:40 AM in the kitchen, observed a stack of frying pans under the food preparation table. The DM stated these are cleaned frying pans. When checked one by one, the second pan from the top was found dirty with dried food debris on the surface (looks like scrambled egg remains) with scratches. The black surface 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.
- Potential for harm · E2025-03-24 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify and provide needed care and treatment for two of 25 sampled residents (Resident 32 and Resident 78) when: 1. The facility failed to follow physician's order to obtain monthly measurements of mid upper arm circumference (MUAC, a tool used to assess nutritional status and help identify people at risk for malnutrition or weight loss, allowing for early intervention) for Resident 32 and Resident 78 who were refusing monthly weights. This failure had the potential to result in Resident 32 and Resident 78 to experience unplanned and undesirable weight loss. 2. The facility failed to implement interventions to monitor Resident 78's injection sites for bruising (skin discoloration from damaged, leaking blood vessels underneath your skin). Additionally, a change in condition was not completed for Resident 78's bruising on the right lower abdomen. This failure had the potential for uneven insulin (a hormone that is injected into the body…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-24 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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
Based on observation, interview, and record review, the facility failed to ensure the accountability of controlled medications (medications with high potential for abuse and addiction), appropriate preparation and accurate administration of medications when: 1. The Controlled Drug Records (CDR, accountability records, an inventory sheet that keeps records of the usage of controlled medications) for five of seven sampled residents (Residents 105, 119, 81,30 and 36) did not reconcile with the Medication Administration Records (MAR). This failure resulted in inaccurate accountability and the potential for abuse and diversion of controlled medications. 2. Nursing staff did not administer correct prescribed medication to one of five residents (Resident 28). 3. Nursing staff did not observe Resident 432 take her medication after leaving one of eight prescribed scheduled medication on the bedside table. 4. Nursing staff did not clean the shared pill cutter in between medication preparations. These failures resulted to medications not given according to the prescriber's orders and/or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-24 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications (drug or medicine, used to diagnose, cure, treat, or prevent disease) and biologicals were properly stored when: 1.The temperature in one of two sampled medication storage rooms did not follow the manufacturer's labeling for proper medication storage. 2.One of two sampled medication storage room refrigerator contained an open and undated multi dose vial (a small bottle of medication that contains more than one dose). 3.Three expired lidocaine (medication that reduces pain) 5% patches were stored in one of three medication carts for Resident 105, readily available for use. These failures had the potential for medications to be ineffective, unsafe for unknown usage timelines and expired that can harm residents. 1.During a concurrent observation and interview on 3/18/25 at 11:51 AM with the Assistant Director of Nursing (ADON), the thermometer in the medication storage room [ROOM NUMBER] indicated a temperature of 78…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-24 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to implement its infection control program when: 1. The urinal used by Resident 45 was stowed inside the trash bin at bedside. 2. During collection of soiled linen on the second floor, the janitor did not perform hand hygiene (the practice of cleaning hands to remove germs, dirt, and other contaminants) before and after glove use. 3. Nursing staff did not perform hand hygiene prior to medication preparation and administration for two of five residents (Resident 432 and Resident 28) and did not disinfect the blood pressure cuff (a device used to measure the force of blood against the artery walls) before and after use for one of one resident (Resident 432). 4. Nursing staff did not wear gloves during medication administration for one of five residents (Resident 433). Failure to implement infection prevention practices may result in cross contamination of infection that may jeopardize the health and safety of the residents and staff. Findings: 1. During an observation on 3/18/25 at 9:13 AM, in Resident 45's room,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-24 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 25 sampled residents (Resident 92 and Resident 7) were treated with dignity and respect when Certified Nursing Assistants (CNA 1 and CNA 2) were standing over residents while assisting them to eat. This failure resulted in the potential for Resident 92 and Resident 7 to feel disrespected and the potential to affect the resident's psychosocial (mental, emotional, social, and spiritual effects) well-being. Findings: 1. Review of Resident 92's admission record indicated, Resident 92 was admitted on [DATE] with diagnoses including type 2 diabetes mellitus (high blood sugar), kidney disease, dementia (a progressive state of decline in mental abilities) without behavioral disturbance, and history of falling. Review of Resident 92's Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment dated [DATE], indicated, severe cognitive (mental action or process of acquiring knowledge and understanding through…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-24 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe self-administration of medications for one of 25 sampled residents (Resident 78) when: a. Multiple prescription medications were left at Resident 78's overbed table. b. The interdisciplinary team (IDT- a group of professionals from different disciplines who work together to achieve a common goal) did not determine if the prescription medications left on the overbed table may be self-administered by Resident 78. These failures resulted in the potential for medication error and may place residents on self-administration of medication at risk for adverse health reactions which could negatively impact the resident's physical and psychosocial well-being. Findings: Review of Resident 78's admission record indicated, Resident 78 was admitted on [DATE] with diagnoses including type 1 diabetes mellitus (high blood sugar), end stage kidney disease, and dependence on renal dialysis (person relies on dialysis machines and procedures to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-24 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 one of five residents reviewed (Resident 28) was free from unnecessary medication when Resident 28 has no evidence of monitoring for bleeding for the use of heparin (anticoagulant-commonly known as a blood thinner, a medication that prevents blood clots from forming in the heart and blood vessels). This failure had the potential to result in undetected medication adverse effects, such as bleeding. Findings: Review of Resident 28's admission Record, indicated, Resident 28 was readmitted in the facility on 2/5/25, with diagnoses including fracture (a break or crack in a bone) of left femur (thigh bone) and hemorrhage (bleeding) of anus and rectum (sections of the digestive tract). Review of Resident 28's Physician's Order, dated 2/10/25, indicated, heparin injection 5000 unit/ml (milliliter, unit of measurement), Inject 1 ml subcutaneously (into fatty tissue, just under the skin ) two times per day for DVT (Deep Vein Thrombosis, a blood clot that forms in a deep vein, usually in the leg, which can cause swelling,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 two of five residents reviewed (Residents 32 and 121) were free from unnecessary antipsychotic (drug that affects brain activities associated with mental process and behavior) medications when: 1. There was no evidence of non-pharmacological interventions and PRN (as needed) Seroquel (quetiapine, an antipsychotic medication) was ordered for more than 14 days for Resident 32; 2. There was no evidence of specific behavioral monitoring for Seroquel use for Resident 121. These failures had the potential to result in unnecessary use of medications that could cause somnolence (sleepiness), dry mouth and dizziness. 1. Review of Resident 32's admission Record, indicated, Resident 32 was readmitted in the facility on 8/30/23 with diagnoses including vascular dementia (a progressive state of decline in mental abilities), psychotic disorder (mental illnesses characterized by a significant loss of contact with reality) with delusion (false belief) and mood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-24 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure food preferences for two out of 133 residents (Residents 36 and Resident 68) were honored when: 1. Resident 36 was served hard carrots with order of SOFT VEGETABLES. Texture: Mechanical Soft. 2. Resident 68 was plated the regular menu of fried rice, mixed veggies, and pork slices, when his meal ticket indicated, Serve Chow Mein with chicken OR potstickers. This failure had the potential for residents not receiving their food preferences that will result to poor appetite, and missing the nutritive value of their food leading to weight loss and/or malnutrition. Findings: 1. During concurrent observation and interview on 3/20/25 between 11:45 AM to 1:00 PM in the kitchen tray line, observed Resident 36 was served the regular menu of fried rice, mixed veggies (peas, carrots, corn and beans), and sliced pork. Review of Resident 36 meal ticket indicates: Texture - Mechanical soft; Special Diets ~ Thin Liquids; Notes - SOFT VEGETABLES. Interview with the Cook, Registered Dietitian (RD) and the Dietary Manager…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 10 citations
- Potential for harm · D2024-05-21 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) comprehensive assessment was completed within the required period of 14 days of admission for Resident 1. Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 1. Findings: Review of Resident 1's admission record, indicated, was admitted on [DATE] with diagnoses including osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), repeated falls, liver disease, schizoaffective disorder (a mental health condition characterized primarily by symptoms of schizophrenia and mood disorders), and traumatic brain injury (TBI, an injury usually results from a violent blow or jolt to the head or body). Review of Resident 1's admission MDS assessment with an assessment reference date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-21 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure baseline care plan was developed within 48 hours of admission for Resident 1. A Baseline Care Plan (BCP) includes minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline, injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. Failure to complete the baseline care plan within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 1. Findings: Review of Resident 1's admission record, indicated, was admitted on [DATE] with diagnoses including osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), repeated falls, liver disease,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-26 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review, and facility policy review, the facility failed to ensure resident food preferences were provided for 1 (Resident #115) of 4 sampled residents reviewed for food. Findings included: Review of a facility policy titled Resident Food Preferences with a revised date of July 2017, revealed Policy Statement Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will be only ordered with the resident's or representative's consent. The policy revealed, 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Dietary Supervisor/Dietician will document the resident's food and eating preferences in the Dietary Profile and care plan. A review of Resident #115's admission Record revealed the facility admitted Resident #115 on 10/13/2023 with diagnosis that included: aphasia (a comprehension and communication disorder), nausea, metabolic encephalopathy, and malignant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-04-09 · tag F0552 — isolatedEnsure 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
Based on observation, interview and record review, the facility failed to ensure that staff verified that the physician obtained informed consent for administering psychotropic medications before administering psychotropic medications (medications that affected residents' mood and behavior) to one out of 24 sampled residents, and one un-sampled resident, Resident 42, and 54. 1. For Resident 42, the facility failed to verify that the physician and the resident's representative signed the psychotropic medication informed consent form. 2. For Resident 54, the facility failed to verify that the physician signed the psychotropic medication informed consent form. This failure had a potential to expose all residents receiving psychotropic medications at the facility to the risk of adverse drug events (medicated related harm during care activities), with the potential to result in residents' injuries and compromising their health and safety. Findings: 1. During a review of Resident 42's admission Record, dated 4/8/21, the admission Record indicated that: i. The facility admitted Resident 42…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-04-09 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to verify resident's ability to self-administer medication, and did not ensure that interdisciplinary team (IDT) evaluated the safety of resident's self-administration of the medication, for one un-sampled resident, Resident 93. This failure had a potential to expose all residents requesting to self-administer medications to the risk of adverse drug events (medication related harm during care activities), with the potential to result in residents' injuries, and compromising their health and safety. Findings: During a review of Resident 93's admission Record, dated April 8, 2021, the admission record indicated that: i. The facility admitted Resident 93 on 7/13/18 for rehabilitation. ii. Resident 93 was admitted with diagnoses that included type 1 Diabetes Mellitus with Retinopathy (loss of vision), glaucoma (increased eye pressure), blindness right eye and normal left eye amongst others. During a review of Resident 93's complete Minimum Data Set (MDS-assessment tool) dated 3/26/21, the MDS indicated that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-04-09 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 ensure staff administered medication according to nationally recognized professional standards of practice for two out of 24 sampled residents, and five un-sampled residents, Resident 26, 27, 42, 63, 73, 91, and Resident 93. This failure had potential to expose all residents receiving medication at the facility to the risk of adverse drug events (harm resulting from medication related care activities), with the potential to result in residents' medication related harm, and compromising their health and safety. Findings: During medications administration observation on 4/7/21, at 08:00 a. m., the following practices were observed: i. The facility mounted a computer containing residents electronic Medication Administration Records (MAR), on top of the Medication Administration Cart 1. ii. LVN 2 logged onto the electronic MAR to prepare to administer medication to residents. iii. LVN 2 placed a 30 milliliters (mls) medication cup on top of the medication cart, opened residents electronic MARs, selected…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-04-09 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one resident (Resident 59), prescribed enteral tube feeding was followed when: a) Resident 59 received the wrong prescribed enteral nutrition (known as tube feeding [TF]- a way of delivering nutrition/food directly to the stomach or small intestine) formula . b)The TF site dressing was not changed on 4/8/21. This deficient practice has the potential for Resident 59 to receive low caloric requirement resulting in malnutrition, dehydration, and weight loss. This deficient practice has the potential for Resident 59's TF site to develop growth of organisms that will cause infection. Resident had history of sepsis. Resident 59 was observed receiving enteral nutrition through his gastric tube (G-tube - a medical device used to provide nutrition to people who are unable to swallow. It is inserted through the belly directly to the stomach). Findings: During an observation of Resident 59 on 4/6/21 at 9:45 AM, the resident was observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-04-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications labeling included current expiration dates, and staff followed cautionary instructions documented on medication labels, for one of 24 sampled residents, in one out of six medication carts, and one out of three refrigerators. 1. For Resident 91, the facility failed to ensure staff followed cautionary instructions documented on medication label before administering medication to her. 2. For Second Floor Medication Room Refrigerator and Third Floor Medication Cart 2, the facility failed to ensure that staff did not store medication with expired dates. This failure had potential to expose all residents receiving medication at the facility to the risk of adverse drug events (harm resulting from medication related care activities), with the potential to result in residents' medication related harm, and compromising their health and safety. Findings: 1. During a review of Resident 91's admission Record, the admission Record…
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.
- No harm found · Bcited before2025-03-24 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
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 47 of 48 residents' rooms met the required minimum of 80 square feet (sq ft) per resident. This failure has the potential affecting residents' comfort, privacy and overall quality of life. Findings: During an observation on 3/18/2025 starting at 10:00 AM, in the course of the initial tour of the facility conducted on the nursing units of the first, second, and third floors, all the rooms were occupied by two or three residents, with curtain to divide each bed. During an interview on 3/18/25 at 10:20 AM, with the Administrator stated the actual count is 48 rooms from first to third floor, but 47 rooms were less than 80 sq ft. room [ROOM NUMBER] has appropriate room size with 2 beds. There is no room [ROOM NUMBER]. He confirmed that all rooms were equipped for three residents except rooms 8, 25 and 41 which were for two residents. During an interview on 3/18/2025 at 10:26 AM with Resident 1 in Room10, Resident was asked how the space…
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.
- No harm found · Ccited before2021-04-09 · tag F0912 — widespreadProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure 48 of 48 residents' rooms measured at least 80 square feet (sq ft) per resident. This failure had the potential to negatively impact residents' provision of care and quality of life. Findings: During an observation on 4/6/21 starting at 9:08 AM, in the course of the initial tour of the facility conducted on the nursing units of the first, second, and third floors, all the rooms were occupied by two or three residents, and equipped to occupy two or three residents. During an interview on 4/9/21 at 10:41 AM, the Administrator stated that rooms 1 to 49 were less than 80 sq ft. There was no room [ROOM NUMBER]. The actual room count was 48. He confirmed that all rooms were equipped for three residents except rooms 8, 25 and 41 which were for two residents. During multiple resident interviews throughout the survey, there were no complaints regarding the size of the resident's rooms. During the Resident Council meeting conducted on 4/8/21…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$12,685 in federal fines across 1 penalty.
- $12,685 — penalty dated 2025-10-02
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to ASPEN SKILLED HEALTHCARE — 35 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.7 | +1.3 vs chain |
| Health inspection | 3 of 5 | 3.1 | -0.1 vs chain |
| Staffing | 5 of 5 | 3.9 | +1.1 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 34 homes this chain runs (chain average 3.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ASJK LLC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/20/2018 |
| ASPEN SKILLED HEALTHCARE INC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/20/2018 |
| SEQUOIA HEALTHCARE GROUP LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/01/2023 |
| SKBM II LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/22/2025 |
| SKBM LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/08/2025 |
| BRADSHAW, JEFFREY | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | since 01/01/2023 |
| BRADSHAW, PETER | Individual | INDIRECT OWNERSHIP INTEREST | since 07/07/2023 |
| BRADY, VERN | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/01/2023 |
| CASE, RYAN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| ELSNER, ERIC | Individual | INDIRECT OWNERSHIP INTEREST | since 12/20/2018 |
| KIRKWOOD, JARED | Individual | INDIRECT OWNERSHIP INTEREST | since 01/01/2019 |
| ORGILL, CRAIG | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2019 |
| PARTI, RAJESH | Individual | INDIRECT OWNERSHIP INTEREST | since 12/20/2018 |
| PARTI, SHRUTY | Individual | INDIRECT OWNERSHIP INTEREST | since 12/20/2018 |
| PAXMAN, MARCUS | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/01/2023 |
| RAWE, COLTON | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| BASA, EDIL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/30/2023 |
| GO, MARIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/17/2021 |
| JAMALI, MEHRAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2023 |
| ASPEN HEALTHCARE SERVICES LLC | Organization | ADP OF THE SNF | since 01/01/2023 |
| JURADO, FRANK | Individual | ADP OF THE SNF | since 01/01/2023 |
CMS files one row per role, so the 39 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.4M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055963. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-24, 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.