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Lincoln Glen Skilled Nursing

2671 Plummer Avenue, San Jose, CA 95125 · Non profit - Church related · 59 certified beds · (408) 265-3222 Medicare & Medicaid certified

Call the home — (408) 265-3222 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 middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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.

5/5
CMS overall
5 of 5
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

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5120 Cherry Ave
Pharmacy
1405 Foxworthy Ave · (408) 264-0371 · Call to confirm hours
Grocery
1421 Foxworthy Ave · (408) 264-0103 · Call to confirm hours
Park
Kirk Park0.4 mi
1601 Foxworthy Ave · (408) 793-5510 · Typically dawn to dusk
Place of worship
2700 Booksin Ave · (408) 267-3663

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased20.4%10.2%15.4%worse
Long-stay residents who lose too much weight3.5%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.8%0.9%better
Long-stay residents with a urinary tract infection1.6%1.2%2.0%better
Long-stay residents with depressive symptoms1.1%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 worsened19.5%9.8%16.1%worse
Long-stay residents on antianxiety or hypnotic medication1.2%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers1.9%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control18.4%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 table10.1%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents rehospitalized after admission12.1%23.0%22.6%better
Short-stay residents with an outpatient ER visit5.6%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days0.742.251.67better
Long-stay outpatient ER visits per 1,000 resident days0.001.571.80better

* 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.

0.18U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 36% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.741.02Oct 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

1.07
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.80
Aide hours/ resident / day
4.76
Total nurse hours/ resident / day
0.61
RN hoursweekends
22.6%
Total nursing turnover
10.0%
RN turnover

How full it usually is: this home is certified for 59 beds and averages 52.8 residents a day — about 89% occupied, or roughly 6 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 4.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.07 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.80 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.44 hrs/resident/day on weekends vs 4.88 on weekdays — 9% thinner on weekends. RN hours go from 1.26 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 23% 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

11
deficiencies at the latest standard inspection (2025-03-24)
6
at the previous standard inspection (2023-11-13)

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.

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Fcited before2025-03-24 · tag F0700 — widespread
    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 ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for 22 (Residents 35, 9, 24, 15, 14, 8, 19, 16, 10, 21, 7, 13, 29, 30, 33, 39, 253, 38, 37, 1, 50 and 11) of 22 residents who used side or bed rails when: 1. Twenty-two (22) of 22 residents who used side or bed rails were without care plans, 2. The risks of entrapment prior to the installation of side or bed rails were not assessed for 22 of 22 residents who used bed rails, and 3. The bed rail assessments were not updated in a timely manner for 18 of 22 residents (Residents 35, 9, 24, 15, 8, 19, 16, 10, 21, 7, 13, 29, 30, 33, 39, 38, 37 and 11). These failures had the potential to place the residents at risk for entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) and injury. Findings: 1a. During the observation of Resident 35, on 3/17/25 at 2:18 p.m., Resident 35 was in bed, confused…

    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 · Fcited before2025-03-24 · 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 keep the exterior of the kitchen's ice machine free of dust. This failure placed all 51 residents at risk of food contamination (unintended presence of potentially harmful substances such as microorganisms, chemicals, or physical objects in food.) Findings: During an observation and interview with the Food Service Manager (FSM) on 3/20/25 at 2:00 p.m. in the facility's kitchen, the exterior side panel of the ice machine was covered in dust. Clean plates were also placed next to the dusty side of the ice machine. The FSM confirmed the observation and stated that the area was dusty. During a concurrent interview and review of the facility's Cleaning Assignments Checklist, provided by the FSM, indicated that staff were responsible for sanitizing the ice scoop, scoop holder, and exterior of the ice machine. The FSM stated that kitchen staff clean the exterior of the ice machine every evening shift. During an interview on 3/20/25, at 2:10 p.m., the Director of Support Services (DSS), who was also present in the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-24 · 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 ensure medications were stored appropriately when: 1. Opened medications without open date were found in Station 1 and Station 2 medication carts, and one expired medication was found in Station 1 medication cart. This had the potential for residents to be given expired or past open-period medications. 2. A medication cart with medications was left unlocked. This had the potential for access to medications by unauthorized persons such as unauthorized staff, residents, and visitors. Findings: 1a. During an observation on Station 1 medication cart with registered nurse D (RN D) on [DATE], at 12:43 p.m., an opened bottle of docusate sodium (stool softener) 250 milligrams (mg, a metric unit of mass) and an opened bottle of guaifenesin (cough and cold medication) 100 mg/5 milliliters (ml, a metric unit of volume) did not have and open date for each bottle; and one container of hyoscyamine sulfate (treats the symptoms of condition that affects…

    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 · Ecited before2025-03-24 · 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 ensure staff followed proper infection control procedures when: 1. Certified Nursing Assistant F (CNA F), Certified Nursing Assistant G (CNA G), and Activities Leader H (AL H) delivered meal trays to Resident 6, Resident 21, and Resident 24 without sanitizing their hands; 2. Licensed Vocational Nurse E (LVN E) used paper towel to wipe the first drop of blood on Resident 4's finger; 3. Employee food was placed on Resident 27's overbed table; 4. Resident 40's filter of oxygen concentration was dusty, and her humidifier bottle was not changed within 5 days; 5. Home Health Aids I (HHA I) walked out of Resident 46's room without sanitizing her hands; and, 6. For Resident 7, LVN E did not perform proper hand hygiene practices during wound care. These failures had the potential to increase the risk of spreading infections in the facility. Findings: 1. During a lunch observation on 3/17/25, at 12:08 p.m., certified nursing assistant F (CNA F) pushed the meal cart then brought the lunch tray to Resident 6 without…

    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 · D2025-03-24 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat the residents with dignity for one of two residents, (Resident 1), when Resident 1's urine drainage bag was not covered. This failure had the potential to cause embarrassment and feeling low self-esteem for the resident. Findings: Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE] with retention of urine diagnosis. Review of Resident 1's physician order, dated 11/26/24, indicated Resident 1 had a Foley catheter (a device that drains urine from the urinary bladder into a drainage bag outside of the body when the person cannot urinate on his/her own). During an observation and interview with licensed vocational nurse A (LVN A) on 3/17/25, at 9:28 a.m., Resident 1 was lying in her bed. Her urine drainage bag was hung on the bed side and was not covered. LVN A stated Resident 1's urine drainage bag should be placed in a cover bag. Review of the facility's policy, Dignity, dated 2/2021, indicated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-24 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool and care screening tool) for pressure ulcers for one of 14 sampled residents (Resident 7). This failure could lead to an inaccurate resident assessment. Findings: A review of Resident 7's Treatment Administration Record (TAR) for January 2025 indicated the resident received daily treatment for a pressure injury on the sacrum. A review of the TAR for October 2024 also indicated daily treament for pressure injury on the sacrum. A review of Resident 7's Section M of the MDS dated [DATE] and 1/31/25 inidicated that Resident 7 was not coded as having a pressure injury on the sacrum (large, triangular bone located between the hip bones.) During an interview and record review on 3/20/25 at 10:38 a.m., the Minimum Data Set Coordinator (MDSC) reviewed Resident 7's TAR and other clinical records related to the pressure injury. The MDSC confirmed that Resident 7 received treatment during…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-24 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the resident care plans were reviewed and updated for effectiveness in four of fourteen sampled residents, (Residents 6, 35, 43 and 44), when the activity care plans of these four residents were not reviewed and updated quarterly. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. During the observation of Resident 6 on 3/17/25 at 1:55 p.m., Resident 6 was laying in her bed, alert, calm, comfortable and verbally responsive. Review of the admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) of Resident 6 indicated, Resident 6 was admitted to the facility on [DATE] with primary diagnosis of unspecified chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow and make it difficult to breathe). 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, the residents received the necessary care and services for one of 13 residents, (Resident 40), when there were no physician order and no care plan for Resident 40's skin discoloration on her left and right forearm. This failure had the potential to affect the resident's care and could jeopardize her health and well-being. Findings: Review of Resident 40's admission Record indicated she was admitted to the facility on [DATE]. During observations on 3/17/25 at 10:30 a.m. and on 3/21/25 at 11:09 a.m., Resident 40 had skin discoloration on her left and right forearm, but there was no physician order and no care plan for the discolorations. During an interview with the director of nursing (DON) on 3/21/25, at 11:27 a.m., she reviewed Resident 40's clinical record and confirmed that Resident 40 did not have physician order and care plan for the discoloration on her left and right forearm. The DON stated, a physician order and care plan…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure provision of care and services related to pressure ulcers were consistent with professional standards of practice for one of fourteen sampled residents (Residents 35), when there were no wound measurements for Resident 35's three wound assessments. These failures had the potential for the residents with pressure ulcers, not being properly monitored and treated which could delay the healing or worsen the wound. Findings: During the observation of Resident 35 on 3/17/25 at 2:18 p.m., Resident 35 was laying in her bed, awake, confused, and unable to answer questions. Review of Resident 35's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident), indicated, Resident 35 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors) with…

    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 · D2025-03-24 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the effective use of medications for one of 13 residents (1) when Resident 1 received ferrous sulfate (iron, for prevention/treatment of iron deficiency) and Calcium+D3 (a medication used to prevent or treat low blood calcium levels) at the same time. This failure had the potential for the resident to not receive the amount of prescribed iron supplement. Findings: Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE] with anemia (a condition that develops when the blood produces a lower-than-normal amount of healthy red blood cells) diagnosis. Review of Resident 1's clinical record indicated, she had physician orders for ferrous sulfate 325 milligrams (mg, a metric unit of mass) every other day for anemia at 9 a.m., started on 11/28/24, and for Calcium+D3 600-20 mg-microgram (ug, a metric unit of mass) two times a day, at 9 a.m. and 6 p.m., started on 2/19/25. Thus, since 2/19/25, ferrous sulfate 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2025-03-24 · 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 5 residents (42) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 42 received Lorazepam (used to treat people with anxiety who frequently have intense, excessive and persistent worry and fear about everyday situations) without specific and documented indication. This failure resulted in unnecessary medications for the resident, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, and memory loss. Findings: Review of Resident 42's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 42's physician order indicated she had an order for Lorazepam 2 milligrams (mg, a metric unit of mass)/milliliter (ml, a metric unit of volume), give 0.25 ml every 6 hours as needed for anxiety 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-13 · tag F0700 — pattern
    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

    Based on observation, interview and record reviews the facility failed to follow their policy and procedure (P&P) by using bed side rails (SR: adjustable metal or rigid plastic bars that attached to the side of head of the bed) before attempting to use alternatives first for 14 of 14 residents (Residents 1, 8, 10, 19, 20, 24, 33, 34, 36, 38, 40, 48, 201, and 202). This failure had the potential to put the residents at risk for entrapment, serious injury and limiting their sense of independence. Findings: During the initial tour of the facility conducted on 11/6/2023 at 8:30 a.m., Residents 1, 8, 10, 19, 20, 24, 33, 34, 36, 38, 40, 48, 201, and 202, all had quarter SR elevated for their beds. Review of clinical records for Residents 1, 8, 10, 19, 20, 24, 33, 34, 36, 38, 40, 48, 201, and 202, lacked, documented evidence the facility attempted alternative approaches prior to using SR for beds. During an interview with license vocational nurse E (LVN E) on 11/8/2023 at 4:02 p.m., LVN E stated no alternatives for SR were tried before SR were used for residents' beds. During an interview…

    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 · D2023-11-13 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document the status of residents' advance directives (AD, a written set of instructions, such as a living will or durable power of attorney for health care when the individual is incapacitated) for two of seven residents (Residents 20 and 34), when their clinical records lacked documentation for them. These failures had the potential for residents' wishes to not be fulfilled, should they become incapacitated. Findings: Resident 20 was admitted with diagnoses of TIA (Transient Ischemic Attack, a stroke that lasts a few minutes) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Alzheimer's disease (a progressive diseases that destroys memory and other important mental functions), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), and dementia with agitation (loss of memory, language, problem-solving and other thinking abilities…

    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 · D2023-11-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment with comfortable sound levels, for one of fourteen sampled residents (Resident 201), when there were episodes of noise in the adjacent room of Resident 201 that was loud and bothersome to her. This failure had the potential to affect the sleep, comfort, and overall well-being of the resident. Findings: During a concurrent observation and interview of Resident 201 on 11/6/23 at 12:28 p.m., she was in her bed, eating her lunch. Resident 201 was alert, oriented, and verbally responsive. Resident 201 stated that the noise level in the next room can be loud, especially in the mornings when staff were getting carts and supplies. Review of Resident 201's face sheet (a document that gives a resident's information at a quick glance) indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stage 3 chronic kidney disease (CKD, mild to moderate gradual loss of kidney function),…

    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 · D2023-11-13 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    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 the Office of the State Long-Term Care (a range of services and supports residents may need to meet their personal care needs for daily living) Ombudsman (advocates for residents in nursing home) was notified in writing when Resident 10 was transferred to the general acute care hospital (GACH). This failure had left the Long-Term Care Ombudsman unaware of of Resident 10's hospital transfer. Findings: Resident 10 was admitted to the facility with diagnoses which included Type 2 diabetes mellitus with diabetic chronic kidney disease, Stage 3 chronic kidney disease, retention of urine (a condition in which the resident is unable to empty all the urine from the bladder [a hollow shaped organ in human body that holds urine]), atherosclerosis (thickening or hardening of the arteries) of CABG (coronary artery bypass graft, is a surgical procedure used to treat coronary heart disease. It diverts blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply to the heart.), anemia (a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents' environment remained free of accident hazards to prevent avoidable accidents, and provide safe environment for residents when: 1. Wheelchairs (a mobility aid device with wheels for use indoors and outdoors, intended for residents who are unable to walk and bear weight on their feet) were placed in-front of room A's bathroom door, which blocked it; and, 2. An antiskid mat was peeling off in room B's bathroom entrance. These failures had the potential for accidents that may result in injury to residents. Findings: 1. During an observation on 11/6/2023 at 10:30 a.m., two wheelchairs were placed in front of the bathroom door in room A. These two wheelchairs blocked the way to bathroom. There was a sign posted on bathroom door indicating, Please do not block door. During an interview with certified nursing assistant B on 11/6/2023 at 10:35 a.m., CNA B acknowledged two wheelchairs blocked Room A's bathroom door; and that, a sign posted on the bathroom's door indicated not to block it. CNA B stated…

    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 · D2023-11-13 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 appropriate psychosocial services were provided for two of fourteen sampled residents, (Residents 40 and 1), when: 1. For Resident 40, no psychosocial follow up was done after her altercation with Resident 1; and, 2. For Resident 1, no psychosocial follow up was done after her altercation with Resident 40 and a room transfer. These failures had the potential for the residents, not to attain or maintain the highest practicable physical, mental and psychosocial well-being. Findings: 1. During a concurrent observation and interview of Resident 40 on 11/6/23 at 9:05 a.m., Resident 40 was laying in her bed, alert and verbally responsive. Resident 40 stated that her roommate, Resident 1, tried to hit her yesterday but she was fine. Review of Resident 40's clinical records indicated, Resident 40 was a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses including, stage 3 chronic kidney disease (CKD, mild to moderate…

    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 · Ecited before2022-05-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided to three of three sampled residents (Resident 40, Resident 7, and Resident 28) when: 1. Resident 40, who was at risk for falls and injury as indicated in the care plan, was not given staff supervision with oversight and cues while walking in his room and while in the corridor or hallway; 2. One staff used an EZ stand lift (battery-powered equipment designed to facilitate toileting, changing of briefs and conducting pivot transfers for weight bearing residents for Resident 7 when two staff were required; and 3. For Resident 28, facility staff did not provide supervision while using a merry walker (adaptive equipment, walker/chair combination) in the hallway. These failures had the potential to result in injury and/or accidents to Resident 40, Resident 7, and Resident 28. Findings 1. Record review of Resident 40's face sheet, dated 7/14/2021, indicated Resident 40 had dementia (a group of conditions resulting in memory loss and impaired judgment), chronic kidney 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-05-20 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility document review, the facility failed to make certain all nursing staff (licensed nurses and certified nursing assistants) had completed the appropriate competency and skill check to demonstrate the proper and safe use of EZ stand lift during resident care. Competency and skills check would ensure staff had demonstrated the correct use of the equipment which would help prevent any possible accidents and/or injury during care. During an observation on 5/16/22 at 1:33 p.m., certified nursing assistant H (CNA H) used EZ stand lift (a battery powered equipment designed to facilitate toileting, changing of briefs and conducting pivot transfers for weight bearing residents) to change Resident 7's incontinent pad by herself when this resident required two staff assistance with transfer and toilet use. A review of the undated facility's lesson plan on Use of the Power Lifts and Scales, utilized to provide in-service to staff, indicated proficiency of CNAs (certified nursing assistants) included performance standard that required the student/staff…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-05-20 · 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

    Based on observation, interview, and record review, the facility failed to ensure that medications were stored safely and properly when: 1. One Levemir insulin (long acting insulin) vial for Resident 8 was being used past the discard date; 2. One discontinued Lactulose (laxative for treatment of chronic constipation in adults and geriatric patients) solution for Resident 39 was still in the medication cart and with no open date; 3. One nursing staff did not count the narcotic (controlled substance) tablets properly during end of shift narcotic count. Findings: 1. During a medication cart observation on 5/17/2022 at 3:00 p.m., an opened Levemir 100 unit (u, standard units of measurement) per milliliter (ml, unit volume for liquids) vial was used past the discard date. The manufacturer's label indicated, opened date 4/4/2022. Discard date 5/16/2022. During a concurrent interview with licensed vocational nurse B (LVN B), she confirmed the above observation. LVN B further stated that the insulin vial should not be used past the discard date. Review of facility's policy on Administering…

    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 · E2022-05-20 · tag F0801 — pattern
    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 observations, interviews, and facility document review, the facility failed to ensure the registered dietitian comprehensively carried out the functions and evaluated the effectiveness of Food and Nutrition Services when temperatures were not properly monitored for the refrigerator and freezer. Failure to ensure dietetic services systems are accurately and effectively evaluated may result in the potential for foodborne illness thus compromising the nutritional status of the residents. Findings: Review of facility documents titled Storage Temperature Record Unit 1 Equipment Walk in Refrigerator, dated April 2022 and May 2022 indicated the acceptable temperature was 41° F (degrees Fahrenheit) and five out of the 60 temperatures documented were above 41° F (4/29 44° F, 4/30 47° F, 5/2 48° F, 5/14 42° F, 43° F). The Action Taken column was blank for the entire document. Review of facility documents titled Storage Temperature Record Unit 2 Equipment Walk in Freezer, dated March 2022, April 2022, and May 2022 indicated the acceptable temperature was 0° F and 152 out of 152…

    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 · E2022-05-20 · tag F0803 — failed to meet residents' dietary needs — pattern
    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 ensure the planned menu was followed for six residents (Residents 13, 19, 24, 32, 34, and 38) on pureed diets (texture modified diets for people with chewing or swallowing difficulties) and two residents (Residents 8 and 36) on controlled carbohydrate soft diet (CCHO, modified diet for people with diabetes to keep the same amount of carbohydrates every day). This failure had the potential to result in not meeting the nutritional needs of the residents. Findings: Review of the facility menu Daily Spreadsheet for Monday 5/16/2022 lunch indicated the followings; cilantro rice puree #8 (1/2 cup) for the Pureed diet and cilantro rice #8 for the CCHO soft diet. During an observation of the lunch meal service on 5/16/22 at 11:52 a.m. in the kitchen, food service worker G (FSW G) used # 12 scoop (1/3 cup) to serve the pureed rice and # 16 scoop (1/4 cup) for the CCHO soft rice. During an interview and concurrent record review with FSW G on 5/16/22 at 12:01 p.m., she reviewed the Daily Spreadsheet for Monday 5/16/22…

    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 before2022-05-20 · 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 food was stored and labeled in accordance with professional standards for food service safety when: 1. Outdated ground beef was stored in the kitchen refrigerator; 2. Undated shakes were stored in the resident food refrigerator. This failure had the potential to expose the residents to expired food products. Findings: 1. During the initial kitchen tour on 5/16/22 at 9:07 a.m., two five-pound packages of ground beef dated 5/12/22 - 5/15/22 were stored in the kitchen walk-in refrigerator. During an interview with dietary supervisor F (DS F) on 5/16/22 at a.m., he confirmed the two five-pound packages of ground beef was dated 5/12/22 - 5/15/22. During an observation on 5/16/22 at 11:20 a.m., DS E took the two five-pound packages of ground beef out from the kitchen. During an interview with the registered dietitian (RD) on 5/17/22 at 3:37 p.m., she acknowledged the two five-pound ground beef dated 5/12/22 to 5/15/22 should have been used by 5/15/22. During an interview with DS E on 5/19/22 at 9:50 a.m., he…

    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 before2022-05-20 · 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 implement infection control practices for COVID-19 (cause of global pandemic; highly infectious respiratory virus) on a yellow unit (unknown COVID-19 status) when: 1. Registered nurse C (RN C) failed to wear required personal protective equipment (PPE, protective equipment including goggles, face shield, masks, gowns, and are designed to protect the wearer from infection) face shield or goggles while in close contact with Resident 12; 2. Certified nursing assistant A (CNA A) failed to wear required PPE while providing direct resident care to Resident 35. 3. CNA I did not perform hand hygine in between resident contact while distributing meal trays to four residents and before assisting Resident 4 with her meals. 4. CNA I did not wear an isolation gown while providing direct resident care to Resident 4 and CNA I did not wear face shield while in the resident care area. These deficient practices had the potential to result in a cross-contamination and the spread of infection for all 48 residents. Findings 1.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to provide wound treatment as indicated in the physician's order, and failed to ensure timely follow-up with the wound clinic to clarify what appropriate treatment would be continued after her appointments were canceled twice for one of two sampled residents (Resident 29). This deficient practice had the potential for Resident 29's heel to worsen. A review of Resident 29's facesheet indicated diagnoses of non-pressure chronic ulcer (arterial ulcers that results from an inadequate blood supply due to peripheral vascular disease, diabetes mellitus, trauma, etc.) on the left foot and congestive heart failure (CHF, a heart condition that causes symptoms of shortness of breath, weakness, fatigue, and swelling of the legs, ankles, and feet). Her Braden scale (an assessment tool to predict risk of pressure injury/ulcer) dated 3/13/22 indicated a score of 14 or moderate risk to develop pressure ulcer/injury (sores (ulcers) that happen on areas of the skin that are under pressure). A review of Resident 29's Non-pressure…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-20 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 396) was free of a significant medication error when Resident 396's Eliquis (a prescription medicine used as a prophylaxis (preventive treatment) against stroke with atrial fibrillation (AF, an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) was not administered as ordered by the physician. This resulted in Resident 396 not receiving 18 doses of Eliquis while in the facility. This deficient practice could increase Resident 396's risk of developing a blood clot due to diagnosis of AF and history of cerebrovascular accident (CVA, the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain). Findings: Per review of Resident 396's clinical record, the resident was admitted to the facility on [DATE], with diagnoses including: hemiplegia following cerebral infarction left nondominant…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-20 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 provide a safe and comfortable environment; 1. Alcohol beverages for a resident was stored open to the resident's hallway in unlocked pantry, without any inventory system for the alcohol, and without any tracking for the resident; 2. An accessible blanket heater in operation was stored open to the resident's hallway in an unlocked linen closet; This had the potential to adversely affect the health and safety of those 48 residents and any visitors in the facility. Findings: During observation, on 5/19/2022 at 9:49 a.m., three residents were walking in the hallway which connected both resident hallways. During this observation, two more residents were outside the resident pantry in wheelchairs. 1. Record Review of Resident 21's physician orders, dated 4/30/2021, indicated Resident 21 may have an occasional alcoholic beverage such as beer or red wine. During interview with the director of nursing (DON), on 5/17/2022 at 1:20 p.m., indicated that in order to have alcohol, a resident must have a physician order for…

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

    Environmental 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.

Who owns this facility

Owner / managerTypeRoleShareSince
LINCOLN GLEN MANOR FOR SENIOR CITIZENSOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF100%since 11/21/2008
COLE, TYLERIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2023
DILL, OUIDAIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/13/2025
DURFEE, DONIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/13/2025
ELDRIDGE, DIANEIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/13/2025
KROEKER, LORENIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 10/01/2024
OLLENBURGER, RANDYIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2010
PENNER, DARYLIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2015
POWELL, JUDYIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2011
WIENS, MARYIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2012
MORTENSEN, BRADIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2022

CMS files one row per role, so the 24 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

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

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.

$7.5M
Net patient revenuemost recent cost report
-17.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 68%Medicare 1%Other / private 31%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$501per resident / day
operating cost
$15,238per month
≈ monthly operating cost
$428per 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 555363. 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.

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