Vista Manor Nursing Center
120 Jose Figueres Avenue, San Jose, CA 95116 · For profit - Limited Liability company · 99 certified beds · (408) 272-1400 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 21% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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 | 4.8% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 4.0% | 5.4% | check this* — see note marked star below the table |
| 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 | 1.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.5% | 7.3% | 6.5% | better |
| 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 | 7.9% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.8% | 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 | 2.0% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.5% | 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 | 18.9% | 12.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.6% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.3% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.1% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.44 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.72 | 1.57 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
68.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 301 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 69.3% 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 101 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 0.56 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% 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 | 68.0%CMS range 61.8–72.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 7.6–13.0 | 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 | 69.3% | 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 | 76.2% | 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 | 77.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.1% | 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 | 97.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.4%CMS range 6.0–13.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 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 99 beds and averages 87.8 residents a day — about 89% occupied, or roughly 11 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 4.31 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.57 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 3.75 hrs/resident/day on weekends vs 4.54 on weekdays — 17% thinner on weekends. RN hours go from 0.54 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Dcited before2025-07-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1.Occupational therapist A (OT A) did not perform hand hygiene (HH - to clean the hands, including washing with soap and water or using an alcohol-based hand rub [like hand sanitizer]) after removal of gloves and before donning (putting on) of a new pair of gloves and did not change gloves after assisting Resident 2 with toileting; and2.Certified nursing assistant B (CNA B) did not perform hand hygiene after touching Resident 3's environment.These failures had the potential to compromise resident's health and safety, and spread infections to residents, staff, and visitors.Review of Resident 1's clinical record titled, admission Record, dated 4/4/2025, indicated Resident 1 was admitted to the facility with diagnoses including fracture of unspecified part of neck of left femur (a break in the bone just below the hip joint), fibromyalgia (a chronic condition that causes widespread…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-11 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to store food and maintain the kitchen under sanitary conditions when: 1. Several food items were undated for use by dates in the refrigerators, freezers, and dry goods area, 2. Ice buildup was noted on the Dessert Freezer #2, 3. A black electric fan had dust accumulated on its surface, 4. Black residue was on the caulking of the dishwasher round sink and 3-compartment sink. Failure to follow facility procedures and standards of practice for food safety has the potential of exposing residents, who are served food from the kitchen, to foodborne illnesses. Findings: 1. During a kitchen observation and interview on 10/7/24 at 8:11 a.m., with the Registered Dietician (RD), several food items were observed with no use by dates (NUBD) in the following areas/locations and were acknowledged by the RD: 1a. Freezer #1 contained: A pack of diced carrots, with open date 9/29/24 lacked a use by date (NUBD). 1b. Freezer #3: (Meat Freezer) contained: A box of diced grilled chicken breast with open date 10/5/24 lacked a NUBD. 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.
- Potential for harm · Dcited before2024-10-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident 64's clinical record indicated he was admitted on [DATE] with diagnoses including Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and Hemiparesis (muscle weakness of partial paralysis on one side of the body that can affect arms, legs, and facial muscles) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, Dysphagia (difficulty in swallowing) following cerebral infarction and Encounter for attention for Gastrostomy (surgical procedure used to insert a tube, often referred as G-Tube, through the abdomen and into the stomach). Review of Resident 64's Order Summary Report, printed 10/8/24, indicated he had enteral feeding orders that started 4/17/24, and orders for Enhanced Standard Precautions (ESP) for high contact resident care activities r/t (related to) RISK FACTORS Indwelling Medical Device: G-Tube Perform hand hygiene & apply personal protective…
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 · D2024-10-11 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working 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 During observation, interview and record review, the facility failed to maintain equipment for one of 19 sampled residents (Resident 10) when Resident 10's bedside rolling table edge trimmings were peeled off and the footboard of her bed was wobbly (shaky). These failures posed as hazardous risks for injury to Resident 10. Findings: Review of Resident 10's face sheet (summary page of a patient's important information) indicated she was admitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness of partial paralysis on one side of the body that can affect arms, legs, and facial muscles) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), aphasia (a disorder that makes it difficult to speak) following cerebral infarction, Type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-10-07 · 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 store medications in a safe and effective manner when expired medications were found in two of two medication rooms. This failure could result to unsafe medication administration to residents. Findings: During a concurrent observation and interview with nurse supervisor F (NS F) on 10/3/22 at 11:32 a.m , in medication room A, a bottle of acidophilus (probiotic) with an expiration date of 7/2022., was found inside the medication refrigerator. A vial of lorazepam (a medication to treat anxiety) with an expiration date of 9/2022 was also found in the emergency kit. NS F stated it should have been thrown away and have discarded per their policy. During a concurrent observation and interview with NS F on 10/3/22 at 11:41 a.m , in medication room B, two bottles of Resident 58's lansoprazole (a medication to treat prevent and treat stomach ulcer) were found in the medication refrigerator. The first bottle had an expiration date of 9/22/22, and the other bottle was 10/2/22. NS F stated it should have been thrown away…
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 before2022-10-07 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility had a 17.6% medication error rate when five medication errors out of 28 opportunities were observed during medication administration for four residents (Resident 2,50,63, and 122). This failure had the potential to compromise the resident's medical health. Findings: 1. During a concurrent observation and interview on 10/3/22 at 9:27 am, licensed vocational nurse C (LVN C) administered the scheduled morning medications to Resident 2 except metoprolol (blood pressure medication). LVN C stated metoprolol was not available. Resident 2's blood pressure reading was 128/80 mm Hg, the systolic blood pressure(SBP) was 128. Review of Resident 2's physician order, dated 9/12/22, indicated to administer metoprolol 25 milligrams (mg, unit of measurement) 1 tablet two times a day for hypertension and hold if SBP was <110, HR<60. During an interview on 10/3/22 at 2:40 p.m., LVN C stated she missed giving the metoprolol as it was not available. Review of facility's policy, titled Administering Medications, dated 7/1/2020, 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.
- Potential for harm · Ecited before2022-10-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 safety when: 1. Two refrigerators did not have internal thermometers and; 2. A bag of food inside of the resident's refrigerator did not have a label, These failures had the potential to cause the growth of microorganisms and foodborne illness for the 64 residents eating at the facility. Findings: 1. During a concurrent observation and interview with the Registered Dietitian (RD) on 10/3/2022 at 11:49 a.m., in the kitchen, there was no thermometer inside the Refrigerator 1. The RD stated they should have a thermometer inside the refrigerator. During a concurrent observation and interview with the Dietary Supervisor (DS) on 10/3/2022 at 11:58 a.m., in the kitchen, there was no thermometer inside Refrigerator 2. The DS stated they should have a thermometer inside the refrigerator. During an interview with the Director of Nursing (DON) on 10/6/2022 at 11:35 a.m., the DON stated a thermometer should be inside each refrigerator.…
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 before2022-10-07 · 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 ensure infection control practices were implemented when: 1. Staff did not wear N95 masks (a high filtering facepiece device designed to achieve a very close facial fit that filter at least 95% of airborne particles) properly; 2. Certified nursing assistant I (CNA I) did not disinfect the vital signs machine (blood pressure machine, pulse oximeter, thermometer in one machine attached to a pole with tray and wheels) after use; 3. Resident 35's oxygen tubing was not dated and labeled; 4. Licensed nurses did not label and date the oxygen tubing for Residents 12 and 24; 5. Staff did not perform hand hygiene during medication pass; 6. Staff did not disinfect the insulin vial rubber top; 7. Resident 7' oxygen tubing was not dated and labeled and nebulizer (breathing treatment machine) mask was not stored properly; 8. The director of nursing (DON) did not properly wear the N95 mask at the nurse station; 9. The certified nurse assistant K (CNA K) did not go through the COVID-19 (a highly contagious viral infection)…
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 · D2022-10-07 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 328) discharged from Medicare Part A services received a Notice of Medicare Non-Coverage (NOMNC, a form given to Medicare recipients notifying then that Part A coverage is being terminated and providing information on how to file an appeal of that decision) letter in a timely manner. This failure had the potential to prevent the resident from filing a timely appeal of the decision to discharge from Medicare Part A services. Findings: A review of Resident 328's clinical records indicated, Resident 328 was readmitted to the facility on [DATE] with diagnosis of pneumonia (infection of one or both lungs) with debility (physical weakness, especially because of illness). The facility initiated a discharge of Medicare Part A services on 9/14/2022 with benefit days remaining. A review of Resident 328's NOMNC letter indicated, The Effective Date Coverage of Your Current Skilled Nursing & Rehab Services Will End:…
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 · D2022-10-07 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 three employees was screened in accordance with their policies when there was no documentation that a background check was conducted prior to hire. This failure had the potential to compromise the safety and security of the residents. Findings: Review of a faxed letter from the facility to the California Department of Public Health, dated 3/11/22, indicated certified nursing assistant J (CNA J) was accused of hitting and making fun of a resident. Review of CNA J's personnel file indicated she was hired by the facility on 9/6/11. There was no documentation that the facility conducted a background check before hiring CNA J. During an interview with the director of staff development (DSD) on 10/6/22 at 1:36 p.m., the DSD confirmed the facility must conduct background checks before hiring employees. The DSD stated she was not able to find documentation that the facility conducted a background check before hiring CNA J. The DSD further stated she reached out to the facility's corporate, who was also unable to find…
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 13 citations
- Potential for harm · D2022-10-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to develop care plans for four of 18 sampled residents (Residents 18, 24, 175 and 14). 1. For Resident 18, the facility did not develop a care plan to address the use of insulin; 2. For Resident 24, the facility did not develop a care plan to address the use of oxygen; 3. For Resident 175, the facility did not develop care plans to address the use of oxygen and antidepressant medication; and 4. For Resident 14, the facility did not develop a care plan to address the use of anticoagulant (blood thinner). This failure had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. A review of Resident 18's clinical record indicated Resident 18 had a physician's orders dated 7/27/2022 for a routine Humalog (insulin - a hormone used to lower the blood sugar) three times a day and a Humalog sliding scale (varies the dose of insulin based on blood sugar level) before meals and at bedtime for diabetes mellitus (DM - a condition which…
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 · D2022-10-07 · 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 adhere to appropriate professional standard of care for one of two sampled residents (Resident 58) when a licensed nurse forcefully introduces through a gastric-tube (g-tube inserted through the belly) the medication causing leakage. This failure had the potential for residents not to received complete dose of medication. Findings: During an observation on 10/3/22, at 4:56 p.m., in Resident 58's room, Licensed Vocational Nurse A (LVN A) administered medication forcefully via g-tube causing it to leak on Resident 58's abdomen. During interview on 10/3/22, at 5:06 p.m., outside Resident 58's room, LVN A stated that she should have not exerted pressure in giving medication thru g-tube. During an interview on 10/04/22, at 1:30 p.m., with Director of Nursing (DON), he stated, medication thru g-tube should be administered by gravity unless there was a prescriber's order to push. During a review of facility's policy titled Administering Medication Through an Enteral Tube, dated 7/01/2020, indicated, the purpose 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.
- Potential for harm · D2022-10-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the physician's order to apply compression stockings (elastic stockings apply to the legs) to one of 18 sampled residents (Resident 21) related to edema (swelling) of both lower extremity. This failure had the potential to affect the residents physical and mental well being in the facility. Findings: Review of Resident 21's clinical record, Resident 21 was admitted on [DATE], with diagnoses of Hypertensive Heart Disease with Heart Failure (heart condition caused by heart caused by high blood pressure), Heart Failure (the heart muscle is unable to pump enough blood to meet the body's needs). Review of Resident 21's Physician Order, order date 8/13/2021, indicated, Compression stockings to both lower extremity (BLE) one time a day for edema. Apply stockings at 6:30 a.m. Remove stockings at bedtime. Review of Resident 21's Nursing Weekly Observations, dated 10/1/2022, indicated, Edema: 1 plus (a grading system used to determine 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 · D2022-10-07 · 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 18 sampled residents (Residents 175 and 69) were free from unnecessary psychotropic medications (medications that cause changes in mood, feelings or behavior) when: 1. For Resident 175, licensed nurses did not monitor for side effects and target behaviors (behaviors intended to be changed or eliminated by the psychotropic medication); and 2. For Resident 69, licensed nurses did not consistently monitor for side effects and target behaviors, and did not complete an abnormal involuntary movement scale assessment (AIMS assessment, a tool used to monitor for abnormal bodily movements caused by antipsychotic medication). These failures had the potential to compromise the residents' health and well-being. Findings: 1. Review of Resident 175's medical record indicated she was admitted on [DATE] and had the diagnosis of unspecified dementia (mental disorder caused by brain disease or injury) with behavioral disturbance. Review of Resident 175's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-07 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake 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 environment for staff and residents when staff used paper towels to light the pilot light in the oven. These failures had the potential to cause staff injuries and a fire hazard for 66 residents in the facility. Findings: During an observation on 10/3/2022 at 11:22 a.m., in the kitchen, the cook (a person who prepares and cooks food as a job or in a specified way) lit the paper towels three times from the stove top and tried to start the oven's pilot light at the bottom of the oven multiple times. During an interview with the Registered Dietitian (RD) on 10/3/200 at 11:41 a.m., The RD stated that staff should not use paper towels to light the oven's pilot light. The RD further stated lighting up a pilot light using the paper towel was not a safe practice. During an interview with the cook on 10/4/2022 at 9:20 a.m., the cook stated it was wrong to use the paper towel to light the oven's pilot light, and he should not have done that. During an interview with the Director of Nursing (DON) on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-12-19 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility had a 42.86% medication error rate with 12 medication errors during 28 opportunities were observed during the medication passes (med pass, licensed nurses administer medication to residents) for seven of 10 observed residents (Residents 4, 13, 16, 24, 34, 65 and 196). Seven of nine observed licensed nurses made medication errors during the med pass. These failures had the potential to jeopardize residents' medical condition and health. Findings: 1a. During a med pass observation on 12/16/19 at 9:40 a.m., registered nurse E (RN E) administered total five medications to Resident 196. These medications included Lumigan 0.01% eye drop (eye medication for glaucoma, a kind of eye disease) and Pazeo 0.7% eye drops (eye medication for glaucoma). RN E administered these two different eye drops within one minute. During an interview with RN E on 12/16/19 at 9:55 a.m., RN E stated she gave Resident 196's two different eye drop medications within one minute.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-12-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a sanitary condition when: 1. Dietary staff did not cover their hair completely with a hairnet; 2. The interior of the ice machine door and ice bin (the bin inside the ice machine where the ice is collected) had multi-color substance; The portable ice container had brown substance inside the container wall; 3. The can opener had multi-color substances; 4. Food items past use by date stored in Freezer 1; 5. There was no air gap ( no space in-between drain spout and the in-floor drain inlet) for the coffee machine and ice machine drain system; 6. Open bags of food items were not sealed or closed in Freezer 2; 7. Expired food items stored in Refrigerator 1; 8. Ready-to-eat Jello stored next to the fruits in Refrigerator 2; 9. Dishwasher sanitizer test strips was expired; sanitizer of multi-Quat (sanitizer for manual dishwasher and kitchen surfaces) test strips were expired. These failures had the potential to cause forborne illness…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-12-19 · 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 ensure nurse staff follow proper infection control practices during medication passes (med pass: nurse administered the medications to residents per physician's order) for seven of 10 observed residents (Residents 4, 13, 16, 24, 65, 196 and 346 ) and one resident with catheter out of 18 sampled residents (18). These failures had the potential to result in cross-contamination and the spread of infections. Findings: 1. During the med pass observation for Resident 196 on 12/16/19 at 9:40 a.m., registered nurse E (RN E) put the medication tray (oral medications and eye drop in the cup) in Resident 196's bed sheet, then RN E put the same tray back to the medication cart after oral med pass. At 9:46 a.m., after RN E administered one type of eye drops to the resident, the eye drop cap dropped on the floor. RN E's gloved hand picked up the cap from the floor. RN E did not perform hand hygiene and/or change into a new pair of gloves. RN E continued to administer the second type of eye drops to Resident 196. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure to provide privacy and dignity for two of 10 residents (Residents 346 and 65) during medication administration. This failure had potential to exposed residents to the public view and lower residents' self-esteem. Findings: 1.During a medication administration observation on 12/16/19 at 11:52 a.m., licensed vocational nurse C (LVN C) did not close Resident 346's door while LVN C administered insulin injection (medication to lower blood sugar level) to the resident's upper arm. Resident 346 was facing the hallway and exposed to the public view. During an interview with LVN C on 12/16/19 at 12:34 p.m., she stated she should have closed the door to provide privacy to the resident while administering the injection to Resident 346. 2. During a medication administration observation on 12/16/19 at 5:18 p.m., LVN D did not pull the curtain or close the door for Resident 65 while LVN D administer medication to the resident via gastrostomy tube (GT, a soft tube surgically inserted from the abdomen area into…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-19 · 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 ensure interventions to prevent further fall incidents for two out of 18 sampled residents (64 and 73) when: 1. For Resident 64, fall interventions were not implemented to prevent falls. 2. For Resident 73, fall interventions were not reevaluated for effectiveness and implementation. This failure had resulted in repeated falls which could cause further decline in the resident's physical function. Findings: 1. For Resident 64, fall interventions were not implemented to prevent falls. During a review of Resident 64's Record of Admission, indicated Resident 64 was admitted on [DATE] with diagnoses of presence of right artificial hip joint, abnormalities of gait, mobility and posture. During a review of Resident 64's Minimum Data Set (MDS), dated 10/30/19, indicated Resident 64's mental cognition was severely impaired. During a review of Resident 64' Change in Condition Report - Post Fall Interdisciplinary (IDT) Review and Recommendation, indicated 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 · Dcited before2019-12-19 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the controlled substance medications (medication with a high potential for abuse and addiction) was disposed properly for Resident 56. This failure had the potential to result in residents not getting medications per physician's order and potential to cause controlled medication misuse and abuse. Findings: Review of Resident 56's physician order dated 11/30/19, indicated to administer one tablet of Xanax 0.25 milligrams (medication for anxiety; mg, measure unit) every 8 hours as needed for anxiety. Review Resident 56's controlled drug record dated 12/12/19, indicated registered nurse B (RN B) signed to dispose one tablet of Xanax by herself. There was no evidence that Xanax was disposed with two licensed nurses. During an interview with RN B on 12/18/19 at 10:14 a.m., RN B reviewed Resident 56's control drug record and stated she disposed the Xanax on 12/12/19 with another nurse. However, she forgot to ask the other nurse to co-sign for the disposition. RN B stated two nurses should dispose and sign the control…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-19 · 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 properly store medications in a safe and sanitary condition when: 1. Medication Cart 1 (MC 1) had multi-color substances and sticky substance; expired medication stored in MC 1. 2. MC 2 had multi-color substances and sticky substances; pill crusher (device to crush tablet medication into powder) had multi-color substances. Eye drop medication stored with oral medication. Expired medication stored in MC2. 3. MC 3 had multi-color substance; pill crusher had multi-color substances. Expired eye drop medication stored in MC 3. Eye drops stored with oral and cream medication. Insulin (medication to lower high blood sugar level) injection pens had no open or expiration date. 4. MC 4 had multi-color substance and sticky substances. Pill crusher had multi-color substances, medication pill spilled inside MC 4, ripped paper and rubber bands noted inside MC 4. Pill divider (device to cut the pill into half or small pieces) had white substance and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-19 · tag F0802 — failed to prepare enough nourishing food — isolatedProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to employ staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service when: 1. Dietary staff did not know how to check thermometer accuracy correctly during the calibration process; 2. Dietary staff did not know how to correctly check the dishwasher's sanitizer and quaternary sanitizer (sanitizer used to clean kitchen counters, tables and surfaces, and used to manually sanitize dishes). The lack of knowledge regarding food and nutrition services had the potential for dietary staff not being able to carry out their job functions properly and ensure sanitary conditions in the kitchen. Findings: 1a. During an observation on 12/17/19 at 11:42 p.m., [NAME] Q demonstrated how to check the thermometer during the calibration process. [NAME] Q put the thermometer probe (tip) on the bottom of the ice water container and read the temperature. He stated if the thermometer's temperature reached to 32…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to GENERATIONS HEALTHCARE — 27 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 | 4.1 | +0.9 vs chain |
| Health inspection | 5 of 5 | 3.6 | +1.4 vs chain |
| Staffing | 3 of 5 | 3.7 | -0.7 vs chain |
| Quality measures | 5 of 5 | 4.6 | +0.4 vs chain |
The other 26 homes this chain runs (chain average 4.1★, 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 | Share | Since |
|---|---|---|---|---|
| MASTROCOLA, LOIS | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 9% | since 02/01/1998 |
| OLDS, THOMAS | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER | 78% | since 02/01/1998 |
| BMO BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER SECURITY INTEREST | — | since 09/20/2023 |
| LIFE GENERATIONS HEALTHCARE, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/29/2019 |
CMS files one row per role, so the 9 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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 $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 555483. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-11, 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.