All Saint's Subacute & Transitional Care
1652 Mono Avenue, San Leandro, CA 94578 · For profit - Limited Liability company · 86 certified beds · (510) 481-3200 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- 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
- the CMS record shows $163,127 in federal fines (most recent 2025-08-22)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 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 — so a gap this large is worth reading the inspection record for.
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 |
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 fell from 5 to 4 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 | 5.2% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.3% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.1% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 8.9% | 0.4% | 0.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 1.6% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 24.1% | 13.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.4% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 4.4% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.6% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.2% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 93.2% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.68 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.25 | 1.57 | 1.80 | worse |
* 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.
51.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 51.3%CMS range 28.9–70.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.0–15.9 | 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 | not 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 discharge | not 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 discharge | not 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 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 | not 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 familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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. | — | ||
| 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 | 4.2% | 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 | 9.9%CMS range 5.8–14.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.17 | 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 86 beds and averages 63.3 residents a day — about 74% occupied, or roughly 23 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.07 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 6.17 hrs/resident/day on weekends vs 6.70 on weekdays — 8% thinner on weekends. RN hours go from 1.69 to 1.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · Lcited before2025-03-25 · tag F0880 — failed to prevent and control infections — widespreadProvide 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, Facility 2 failed to follow infection control practices to prevent the spread of infection in Facility 2 when the following were identified: 1. Facility 2 did not follow the recommendations to stop the spread of infection as outlined by the local public health department (LPHD). The recommendations were as follows: a.Close Facility 2 to new admissions and halt movement of residents from other buildings to the facility . b.Submission of adherence monitoring logs for hand hygiene, PPE (personal protective equipment, any piece of clothing or equipment that ' s worn by the employees to minimize exposure to biological, chemical, or any physical hazards on work site) use, and environmental cleaning at weekly intervals and contact precaution (infection control measures used to prevent the spread of infectious diseases that are transmitted through direct contact with an infected person or their contaminated environment) and hand hygiene observations of staff to 50 per…
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 before2026-06-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to provide care and services in accordance with professional standards of practice for two of five sampled residents (Resident 1 and Resident 2) for tracheostomy (a surgical procedure that creates an opening through the front of the neck directly into the trachea [windpipe]) care when:1. Resident 1 did not have a physician order for tracheostomy suctioning (a sterile procedure that uses a flexible catheter inserted through the tracheostomy to mechanically clear excess mucus or secretions from the trachea [a critical tube that connects voice box to lungs]) as indicated in Resident 1's care plan, and the facility did not have time-specific documentation demonstrating when the tracheostomy suctioning was provided to Resident 1. 2. Resident 2's manual resuscitator bag (also known as bag-valve-mask, is a hand-held device used in emergencies to provide manual, positive pressure ventilation to patients who are not breathing adequately) maintained at the bedside for emergency respiratory use, was stored unlabeled 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 · D2026-06-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to ensure the implementation of hydration monitoring for one of three sampled residents (Resident 1), when Resident 1's intake (I, fluid consumed) and (&) output (O, fluid excreted) monitoring during the PM shift (7:00 p.m. to 7:00 a.m.) was not maintained and the total 24-hour I&O (it is the clinical window used to evaluate fluid balance and it sums all fluid consumed against all fluid excreted over the preceding 24 hours to track trends and detect dehydration [loss of fluid] or fluid overload [too much fluid in the body]) was not calculated on 6/15/26, to evaluate Resident 1's overall fluid balance and hydration status.This deficient practice placed Resident 1 at risk for delayed identification of changes in fluid balance, including dehydration or fluid overload, and delayed implementation of appropriate interventions.During a record review of Resident 1's admission Record (AR), dated 6/23/26, AR indicated Resident 1 was originally admitted to the facility in March 2015, with diagnoses including traumatic brain injury…
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 · D2026-06-23 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to ensure accurate and complete clinical documentation for one of three sampled residents (Resident 1), when the licensed nurse documented that medications were administered to Resident 1 on 6/16/26 at 5:00 a.m., the medications administration were not documented on Resident 1's Medication Administration Record (MAR- It is the official clinical record log that nurses and caregivers use to document what prescribed medication a patient receives, the dosage, the time it was administered, and the route).This deficient practice resulted in Resident 1's inaccurate and incomplete clinical record, which could affect Resident 1's ongoing clinical assessment, treatment decisions, and continuity of care.During a record review of Resident 1's admission Record (AR), dated 6/23/26, AR indicated Resident 1 was originally admitted to the facility in March 2015, with diagnoses including traumatic brain injury (TBI, a disruption in normal brain function caused by an outside physical force), post traumatic seizures (abnormal electrical…
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 before2026-06-23 · 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
Based on observation, interview and record review, the facility failed to ensure staff adhered to its infection control policies for one of three sampled residents (Resident 3) when housekeeper (HK 1) entered and cleaned Resident 3's room without wearing the required isolation gown (protective barrier to prevent the transfer of germs between patients and staff) while Resident 3 was on contact isolation precautions (safety measure to wear gloves and gown when in contact with an infected resident, surfaces or equipment) for MRSA (methicillin-resistant staphylococcus aureus, bacteria that does not respond to antibiotics) associated wounds to the left foot and left leg, increasing the risk of cross-contamination and transmission of healthcare-associated infections. This failure exposed residents and staff to potential cross-contamination and increased risk of transmission of infectious organisms.Findings: During a review of Resident 3's admission Record, indicated Resident 3 was admitted in the facility on 11/18/24, with diagnoses of Tracheostomy (a surgically created hole in the neck…
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 · D2026-02-09 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide services to meet professional standards of quality for one of three sampled Residents (Resident 1), when Resident 1 did not have their blood sugar level checked and/or received Insulin [medication for Diabetes Mellitus (DM - a chronic condition where the body cannot properly manage sugar in the blood leading to high levels that can damage organs)] as ordered by their physician. This failure had the potential for Resident 1 to experience life-threatening emergencies as well as severe organ damage.During a review of Resident 1's admission Record, dated 12/15/25, the admission Record indicated Resident 1 was admitted to the facility in April 2023 with multiple diagnoses that included Type 2 Diabetes Mellitus with hyperglycemia (high blood sugar) and Gastrostomy Status (indicates a feeding tube (G-tube) placed directly into stomach through the abdominal wall used for long-term feeding, fluids, or medicine when a patient cannot eat enough by mouth).During a review of Resident 1's Minimum Data Set Assessment (MDS- 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 before2026-02-09 · 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 observe infection control measures for two of six sampled residents (Resident 1 and Resident 2 ) when the following was observed: 1. House Keeper (HK) 1 was seen inside Resident 1's room who was on Contact Precaution (extra safety steps healthcare workers take to stop spread of germs) without Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and did not perform hand hygiene after exiting Resident 1's room.2. Registered Nurse (RN) 1 did not wear PPE or wash their hands after giving a subcutaneous (medication delivered through injection under the skin) injection to Resident 1.3. Certified Nursing Assistant (CNA) 1 emptied Resident 2's urinary drainage bag with gloved hands and exited Resident 2's room without removing gloves or performing hand hygiene. These failures had the potential to spread infections among residents at the facility.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.
- Potential for harm · E2025-03-25 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan (a document that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) for four of six sampled residents (Residents 11, 12, 15, and 31), when Residents 11, 12, 15, and 31 did not have a care plan to address their antibiotic-resistant infection called Carbapenemase-Producing Organisms (CPO, are bacteria that are resistant to a class of antibiotics called carbapenems which are typically used as a of last-line treatment for serious infections) specific to enzyme New Delhi [NAME]-ß-lactamase (NDM, an enzyme that makes bacteria resistant to a broad range of antibiotics including the carbapenem family). This failure had the potential for Residents 11,12, 15. And 31 to not receive person-centered appropriate care, monitoring, and treatment. Findings: During a review of Resident 11 '…
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 · E2024-07-12 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure accurate accountability of a controlled substance (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) when: 1. During a random controlled medication use audit, two of two randomly sampled residents (Resident 49 and Resident 15) did not have all administered medications correctly documented on the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medication) and on the Medication Administration Record (MAR) to indicate they were administered to the resident. This failure had the potential to result in misuse or diversion of controlled medications and had the potential to make it more difficult to monitor if medication dosages need to be adjusted. 2. The medication cart was observed to be unlocked on two occasions. This failure had the potential to result in residents…
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 · E2024-07-12 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store and label mediations in accordance with manufacturer specifications and currently accepted professional principles when: 1. Two containers of acetylcysteine (a medication used to break up mucus in people with lung disease) were not labeled with an open date. 2. An unopened insulin pen was stored in the medication cart. 3. Four bottles of eyedrops were not correctly labeled with a patient identifier. 4. Oral (taken by mouth) medications were stored in the same compartment in the medication cart as eye drops. These failures had the potential to result in eight residents potentially receiving an incorrect or expired medication. Findings: 1. During a concurrent observation and interview on [DATE] at 11:45 a.m. with Licensed Vocational Nurse (LVN) 2, there were two open containers of acetylcysteine for Resident 18 and 23 in the medication refrigerator that did not have an open date. LVN 2 confirmed there was no open date or time 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 · E2024-07-12 · tag F0802 — failed to prepare enough nourishing food — patternProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure kitchen staff were competent regarding job duties when: 1. A cook did not know the appropriate method for calibrating the thermometer. 2. A dietary aide did not demonstrate appropriate procedures for testing the sanitizer on the dish machine. 3. Kitchen staff did not know the appropriate sanitizer for sanitizing food contact surfaces. This failure had the potential to result in contamination of kitchen equipment and/or utensils leading to food borne illness caused by pathogens (harmful organisms) for 22 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 7/11/24 at 9:45 a.m. with [NAME] in the kitchen, [NAME] stated she was responsible for the food thermometer's calibration to ensure accuracy. [NAME] showed how to calibrate the food thermometer by filling a stainless cup with cold water and ice cubes, then she added hot water. She inserted the stem of the thermometer into the contents of the stainless cup. [NAME] stated the thermometer stem would…
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 12 citations
- Potential for harm · E2024-07-12 · 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, prepare, and serve food in accordance with professional standards for food safety when the following was noted: 1. Expired and beyond use by date of eight various dry seasonings were available for use. 2. A tabletop can opener was not clean. These failures placed 22 residents who received food from the kitchen at risk for food borne illnesses. Findings: 1. During a concurrent observation and interview on 7/8/24 at 9:32 a.m. with Registered Dietician (RD) in the kitchen, there were opened and used seasonings noted on a wall shelf behind the cooking area. These seasonings were in their original containers, labeled with open, expiration, and use-by dates. Six (6) seasonings were found to be expired: sweet basil, tarragon, ground cloves, crushed Italian Seasoning, Cajun seasoning, and ground ginger, with expiration dates of 3/2/24, 6/2/24, 6/28/24, 7/2/24 and 7/6/24 respectively. Additionally, two (2) seasonings were beyond their use-by date: ground black pepper and ground cinnamon, with use-by date 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 · D2024-07-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 two of three sampled residents (Resident 40 and Resident 59) received assistance with Activities of Daily Living (ADL, those activities needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) to maintain good grooming and personal hygiene when Resident 40 and Resident 59 had long, thick facial hair. This failure resulted in Resident 40 and Resident 59 at risk for skin breakdown and irritation. Findings: 1. During a record review of Resident 59's Resident Face Sheet, printed on 7/11/24, the Face Sheet showed Resident 59 was admitted to the facility in March 2024 and had multiple medical diagnoses including encephalopathy (any brain disease that alters brain function or structure, manifested by declining ability to reason and concentrate, memory loss, personality change, seizures, and twitching are common symptoms) and traumatic hemorrhage of cerebrum (a disease caused by bleeding in the brain…
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 before2024-07-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 one of three sampled residents (Resident 59), received proper tracheostomy (surgically created hole in the trachea or windpipe that provides an alternative airway for breathing) care when Resident 59's tracheostomy tie (a band that goes around the neck and hold the tracheostomy tube in place) was not changed daily as ordered by the physician. This failure resulted in Resident 59 being at risk for skin irritation and infection. Findings: During a record review of Resident 59's Resident Face Sheet, printed on 7/11/24, the Face Sheet showed Resident 59 was admitted to the facility in March 2024. During a record review of Resident 59's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 5/21/24, Resident 59's review of section I (Active Diagnoses) indicated Resident 59 had a diagnosis of dependence on ventilator (a type of breathing apparatus that provides mechanical ventilation by moving breathable air 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 · D2024-07-12 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to act upon consultant pharmacist's recommendations to add the correct indication of use for quetiapine (a medication used to treat certain mental/mood disorders) for one of five sampled residents (Resident 19). This deficient practice resulted in Resident 19 receiving unnecessary medication without proper indication and had the potential to negatively impact the resident's well-being. Findings: During a review of Resident 19's admission Record Report, printed on 7/11/24, the report indicated Resident 19 was admitted to the facility in October 2018. During a concurrent interview and record review on 7/10/24 at 3:11 p.m., with Director of Nursing (DON), Consultant Pharmacist's Medication Regimen Review (MRR) for April 2024 was reviewed. The MRR, dated on 4/27/24, indicated the following: [Resident 19] only taking quetiapine due to failed GDR of quetiapine. Fix diagnosis to dementia with behaviors- biting. The recommendations have not been reviewed by physician as of 7/10/24. During a concurrent interview and record review on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-12 · tag F0912 — isolatedProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide 80 square foot of space per resident for 13 residents who occupied 6 multi-bed bedrooms. This condition had the potential to result in lack of sufficient space for the provision of care both routine and emergency and for residents to have their personal belongings at bedside. Findings: During an observation on 7/8/24 at 10:23 a.m., the following rooms and corresponding square footage (sq. ft) per bed were identified: Room Activity Room Size Floor Area 2 -TCU Resident room [ROOM NUMBER].12 sq ft 77.56 sq ft/bed 3 -TCU Resident room [ROOM NUMBER].12 sq ft 77.56 sq ft/bed 9 -TCU Resident room [ROOM NUMBER].74 sq ft 72.87 sq ft/bed 7-North Resident room [ROOM NUMBER].5 sq. ft 79.75 sq ft/bed 12-North Resident room [ROOM NUMBER].4 sq ft 77.2 sq ft/bed 16-North Resident room [ROOM NUMBER].75 sq ft 77.9 sq ft/bed During random observations of care and services from 7/8/24 to 7/11/24, there was sufficient space for the provision of care…
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 · D2023-09-29 · tag F0573 — isolatedLet each resident or the resident's legal representative access or purchase copies of all the resident's records.
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 representative of one of three residents (Resident 1) received copies of medical records within 48 hours from requested date. This failure resulted in Resident 1's representative (RR) not receiving requested documents for 20 days. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. During a review of the letter requesting medical records, dated 8/16/23, the letter, addressed to the facility's Custodian of Records, indicated a request for Resident 1's medical records to be sent through the following methods: - Contacting the requesting office at their phone number when medical records are located to schedule a copy appointment. - Emailing the records to the requesting office's email address. - Furnishing a copy via facsimile to the requesting office's fax number. - Mailing a copy of the records to the requesting office's mailing address. During a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-03 · 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 observe infection control measures for one of five sampled residents (Resident 1), when Registered Nurse 1 (RN 1) did not wear proper personal protective equipment (PPE) such as gown while providing wound care for Resident 1 who was under transmission-based precaution. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff in the facility. Findings: During a review of Resident 1 ' s admission record, printed on 8/3/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and has a medical diagnosis including MSSA Infection (Methicillin-susceptible Staphylococcus aureus, is an infection caused by a type of bacteria commonly found on the skin). During a review of Resident 1 ' s Care Plan, printed on 8/7/23, the care plan indicated Resident 1 was placed on preemptive contact precaution(Contact precautions prevent 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 · D2022-05-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 that one of two sampled residents (Resident 14) received the physician-ordered treatment for his pressure ulcers. (A pressure ulcer refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device, commonly known as bed sores.) The failure to use the wound treatment ointment ordered by the physician, had the potential to result in delayed healing of Resident 14's pressure ulcers. Findings: A review of Resident 14's admission Record, dated 5/18/22, indicated Resident 14 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (a disorder of high blood sugar level), persistent vegetative state (absence of responsiveness and awareness), and pressure ulcers. A review of Resident 14's Minimum Data Set (MDS, an assessment tool used to guide care), dated 2/7/22, indicated Resident 14 had a Stage 3 pressure ulcer (full thickness skin…
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 · D2019-11-21 · 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 promote dignity and respect for three of 15 sampled residents (residents 8, 28 and 41) when staff were standing over the residents while assisting them to eat. This deficient practice had the potential to cause residents to feel demeaned and disrespected. Findings: During an observation on 11/18/19 at 12:11 p.m. in the Transitional Care Unit dining room, residents 8 and 28 were seated at a table with their dining trays in front of them. Licensed Vocational Nurse (LVN 1) was observed assisting resident 8 with eating while standing next to him. Certified Nursing Assistant (CNA 1) was observed assisting resident 28 with eating while standing next to him. During an interview with CNA 1 on 11/18/19 at 12:44 p.m., she stated she was standing to assist resident 28 with eating because it was more comfortable for her. She stated there is no policy for standing or sitting while assisting residents with their meals. She stated, It is just what you are comfortable doing. During an interview with LVN 1 on 11/18/19 at 12:47…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2022-05-19 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 Discharge Assessment Minimum Data Set (MDS, an assessment tool used to guide care) was completed within 14 calendar days for one of two sampled residents (Resident 53). This failure resulted in delayed completion and submission of Resident 53's Discharge Assessment MDS. Findings: A review of Resident 53's admission Record, undated, indicated Resident 53 was admitted to the facility in 2021 with a diagnosis of respiratory failure (a condition that makes it difficult to breath on your own), and being dependent on a ventilator (a machine to assist breathing). During an interview and concurrent record review on 5/19/22, at 8:17 a.m., with the MDS Coordinator, Resident 53's MDS assessments were reviewed. The MDS Coordinator stated Resident 53 had transferred to the hospital on 1/18/22, and had not returned to the facility. The MDS Coordinator stated there had not been a Discharge Assessment MDS completed or submitted after Resident 53's discharge, which made the MDS Discharge Assessment than 107 days overdue. 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.
- No harm found · Bcited before2022-05-19 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility had six resident (Rt) rooms (Transitional care unit-TCU rooms 2, 3, 9, and North rooms 7, 12, 16) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 5/17/22, at 9:15 a.m., the following rooms and corresponding square footage (sq. ft) per bed were identified: Room Activity Room Size Floor Area TCU #2 Rt room [ROOM NUMBER].12 sq ft 77.56 sq ft/bed TCU #3 Rt room [ROOM NUMBER].12 sq ft 77.56 sq ft/bed TCU #9 Rt room [ROOM NUMBER].74 sq ft 72.87 sq ft/bed North #7 Rt room [ROOM NUMBER].5 sq ft 79.75 sq ft/bed North # 12 Rt room [ROOM NUMBER].4 sq ft 77.2 sq ft/bed North #16 Rt room [ROOM NUMBER].75 sq ft 77.9 sq ft/bed During random observations of care and services from 5/16/22 through 5/19/22, there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2019-11-21 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide bedroom space equal to 80 square feet per resident (sf/resident) in: 1. Building A: three of 11 resident rooms (rooms [ROOM NUMBER]), affecting five of 20 facility residents, and 2. Building B: three of 21 resident rooms (rooms [ROOM NUMBER]), affecting six of 37 facility residents. These failures had the potential to result in inadequate space for delivery of care, or for resident belongings. Findings: During an observation on 11/21/19 from 10:30 a.m. to 11:58 p.m., Building A had two resident occupants per room for room [ROOM NUMBER] and room [ROOM NUMBER], and one resident occupant for room [ROOM NUMBER]. Building B had one resident occupant for room [ROOM NUMBER], and two resident occupants for room [ROOM NUMBER], and three resident occupants for room [ROOM NUMBER]. Record review of room measurements reflected: Building A: room [ROOM NUMBER] = 14 feet (ft) by 11.08 ft = 155.12 square feet (sf) = 77.56 sf/resident; room [ROOM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$163,127 in federal fines across 2 penalties.
- $30,933 — penalty dated 2025-08-22
- $132,194 — penalty dated 2025-03-25
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PACS GROUP — 274 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.9 | +0.1 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 3 of 5 | 2.5 | +0.5 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PROVIDENCE GROUP NORTH LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/20/2016 |
| MUPPU, MANJULA | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 01/01/2023 |
| STOCK, STEVEN | Individual | W-2 MANAGING EMPLOYEE | — | since 04/01/2024 |
| APT, FREDERICK | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| HANCOCK, MARK | Individual | CORPORATE OFFICER | — | since 02/10/2021 |
| JERGENSEN, JOSHUA | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| MITCHELL, JOHN | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $786K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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
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 555809. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.