Bancroft Healthcare Center
1475 Bancroft Avenue, San Leandro, CA 94577 · For profit - Corporation · 39 certified beds · (510) 483-1680 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- about 22% 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 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 | 24.2% | 10.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.6% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 7.3% | 6.5% | check this* — see note marked star below the table |
| 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 | 0.0% | 1.6% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 23.6% | 9.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 3.4% | 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 | 0.6% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 6.5% | 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 | 16.5% | 12.0% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.0% | 93.2% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.67 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.86 | 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.
Therapy staffing: this home’s payroll records show 0.08 therapist hours per resident per day in 2026Q1 — more than 4% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at 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 | 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 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 — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 39 beds and averages 36.4 residents a day — about 93% occupied, or roughly 3 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 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.14 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 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 3.52 hrs/resident/day on weekends vs 3.57 on weekdays — 1% thinner on weekends. RN hours go from 0.12 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2025-08-08 · 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 interview and record review, licensed nursing staff did not provide care according to professional standards for 1 of 3 sampled residents (Resident 1). Resident 1 had been prescribed oxycodone (narcotic) since 2024 and was in hospice (end-of-life care for a terminal illness.) When Resident 1 could no longer swallow her pills, facility staff did not have a plan in place to address withdrawal symptoms from the oxycodone.This resulted in Resident 1 experiencing unnecessary pain, agitation and distress.During a review of Resident 1's clinical document titled admission Record, the admission record indicated, the facility admitted Resident 1 on 12/14/2023 with multiple medical diagnoses including multiple fractures, cerebral infarction (stroke) and chronic pain syndrome. During a review of Resident 1's clinical document titled Physician's Order dated 4/7/2025, the document indicated, Resident 1 was admitted into hospice care with terminal diagnosis of Dysphagia (inability to swallow) due to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-10 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advanced directives (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), were discussed with the residents and/or responsible parties for four out of 14 sampled residents (Residents 17, 2, 22 and 24). This failure had the potential for the facility to provide treatment and services against the residents' wishes. Findings: During a review of Resident 17's admission Record, dated 10/8/24, the record indicated Resident 17 was admitted to the facility with diagnoses that included aphasia following cerebral infarction (aphasia is a disorder that affects how a person communicates, cerebral infarction is a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die). During a review of Resident 17's Minimum Data Set (MDS,…
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 before2024-10-10 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of two sampled residents' (Resident 4 and 21) rooms had comfortable and safe temperature levels. This failure had the potential to cause overheating in residents and discomfort during severe hot weather. Findings: During a review of Resident 4's Annual Minimum Data Set (MDS - Resident assessment and care guide tool), dated 5/24/24, the MDS indicated Resident 4's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 14 and indicated intact mental status. The MDS indicated Resident 4 was able to recall the correct year and month. The MDS indicated Resident 4 had clear speech, able to express her ideas and wants, and understood what others said to her. Resident 4's diagnoses included stroke. 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 · E2024-10-10 · tag F0676 — failed to keep up residents' daily-living abilities — patternEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to use the communication binder (a communication visual tool that is used to help residents communicate their needs) for three of three sampled non-English speaking or aphasic (a language disorder that affects how you communicate) residents (Resident 25, Resident 24, and 17) when: 1. Resident 25 and 24's communication binders were not used, and 2. Resident 17 did not have a communication binder. This failure had the potential for Residents 25, 24 and 17 not to understand and carry out activities of daily living (ADL). Findings: 1. During a concurrent observation and interview on 10/9/24, at 10:00 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 25's room, LVN 1 could not understand Resident 25 as Resident 25 spoke only in her native language. LVN 1 stated she could only communicate with Resident 25 through gestures and pointing. LVN 1 stated she did not know what language Resident 25 spoke. During a review of Resident 25's admission…
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 · D2024-10-10 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), accurately reflect the assessment status for two (Resident 4 and 12) of fourteen sampled residents when 1. Resident 4's MDS section G did not reflect limitation in range of motion to upper and lower extremities (hip, knee, ankle, foot), and 2. Resident 12's MDS section K did not reflect a significant weight loss. These failure had the potential for residents to not receive appropriate care and services. Findings: 1. During a review Resident 4's admission Record (AR), AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis of knee (the wearing down of the protective tissue at the ends of bones cartilage occurs gradually and worsens over time). During a review of Resident 4's care plan review date 9/11/24, the care plan indicated Resident 4 had limited physical mobility to upper and lower…
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 before2024-10-10 · 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 observation, interview and record review, the facility failed to ensure one (Resident 32) sampled resident on tube feeding (Tube feeding refers to the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum. It is also referred to as an enteral feeding.) maintained acceptable nutritional status and body weight range when Resident 32's unplanned weight loss was not reevaluated with appropriate interventions by the Registered Dietician (RD), and the facility did not notify the physician and responsible party of Resident's 32 unplanned weight loss. This failure had the potential to result in Resident 32's dehydration and unplanned weight loss. Findings: During a review of Resident 32's admission Minimum Data Set (MDS - Resident assessment and care guide tool), dated 7/29/24, the MDS indicated Resident 32's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is 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 · D2024-10-10 · 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 observation, interview and record review, the facility failed to ensure one (Resident 18) sampled resident was free from unnecessary drugs when Resident 18 with diagnosis of Alzheimer Dementia was administered Seroquel (Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior) medication without adequate clinical indication for continued usage. This failure had the potential for Resident 18 to receive unnecessary medications and had the potential for the Resident 18 to suffer adverse medication side effects. Findings: During a review of Resident 18's Significant change in status-Minimum Data Set (MDS, Resident Assessment and care guide tool), dated 5/17/24, indicated Resident 18's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling when: 1. One box of expired blood glucose test strips (small, disposable plastic strips that measure blood sugar levels) for Resident 137 was stored in the medication room, 2. A bottle of liquid Lorazepam (medication used to treat anxiety) which belonged to a deceased resident was stored in the refrigerator in the medication room, and 3. A bottle of expired Senna (laxative) tablets was stored in the medication cart 2. These failed practices could contribute to unsafe medication use in the facility. Findings: 1. During a concurrent observation and interview on 10/7/24 at 10:20 a.m. with the Director of Nursing (DON), one box of expired blood glucose test strips with an expiration date of 2/25/21 for Resident 137 was found stored in the medication storage room. DON stated the expired blood glucose strips should have been disposed. Review of Resident 137's admission Record (AR) dated 10/10/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-10 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure one (Resident 7) sampled resident received and consumed foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician when Certified Nursing Assistant (CNA 5) served Resident 7 a meal tray of pureed diet that belonged to Resident 13. This failure had the potential to cause residents to receive and consume foods that are not in the appropriate texture and nutrient content to support the resident's needs cause choking or food allergy. Findings: During a review of Resident 7's Significant change in status-Minimum Data Set (MDS - Resident assessment and care guide tool), dated 12/25/23, the MDS indicated Resident 7's was on a mechanically altered diet. Resident 7 needed partial to moderate assistance with eating. The MDS indicated Resident 7's diagnoses included Aphasia (a language disorder that affects a person's ability to communicate) and stroke. During an observation on 10/8/24 at 12:10 p.m. in the Dining Room (DR) there were six residents eating in the dining room.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-16 · tag F0572 — patternGive residents a notice of rights, rules, services and charges.
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 inform residents in a language they understood of their rights, all rules and regulations governing residents conduct and responsibilities during their stay at the facility for nine of nine sampled residents (Resident 5, 6, 8, 11, 21, 24, 25, 27 and 133), who were identified as Chinese speaking residents. A California ombudsman essentially helps senior victims of abuse or neglect to understand their rights within the legal system and reach a proper resolution}. This failure had the potential to cause residents emotional distress and despair. Findings: Review of the admission record indicated Resident 21 was Chinese and their primary language is Chinese. Resident 21 was admitted to the facility on [DATE]. During a resident council meeting on 11/14/23 at 10:04 a.m., through a phone translator (PTL), Resident 21 stated he did not know who to talk to when he had grievances. Resident 21 stated he did not know about the Ombudsmen or their phone numbers. (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 · Ecited before2023-11-16 · 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 and interview, the facility failed to ensure storage of food under sanitary conditions when; - one carton of thickened Apple Juice from concentrate was opened with no use- by-date; - three containers of mayonnaise opened with no use-by-date; - five brownish, discolored juice cups ready for use; - one container of chopped garlic in oil opened with no use- by-date; - staffs' personal food items of tea, cooked eggs and cell phone were placed on the kitchen preparation table; - two bags of vegetables placed on the 2-compartment sink next to dishwashing area. These failures had the potential to result in food borne illness for residents who received food from the facility's kitchen. Findings: During the initial tour of the kitchen on 11/13/23 at 9:10 a.m., accompanied by the Dietary Manager (DM), the following were observed: one cartoon of thickened Apple Juice from concentrate was opened with no use- by-date; three containers of mayonnaise opened had no use-by-date; five brownish discolored juice cups ready for use, and one container of chopped garlic in oil opened…
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 19 citations
- Potential for harm · D2023-11-16 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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 (Resident 24) sampled resident's Pre-admission Screening Resident Review (PASRR) for serious mental illness was accurately completed and referred to the appropriate state mental authority for Level II evaluation and determination. This failure had the potential to prevent Resident 24 from receiving appropriate required mental health services. Findings: Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 10/13/23, indicated the PASRR was coded zero-meaning, Resident 24 was not considered by the State Level II PASRR process to have a serious mental illness. However, Resident 24's diagnoses included Bipolar disorder (mood disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the PASRR screening dated 9/13/22 indicated Resident 24 did not have a diagnosed mental disorder such as depression, anxiety, panic and/or mood disorder. During an interview and concurrent record review, on 11/14/23 at 11:10 a.m., with Registered…
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 before2023-11-16 · 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 interview and record review, the facility failed to implement the nutritional interventions for one (Resident 29) of one sampled resident with significant weight loss. This failure had the potential to result in continuous weight loss, fluid imbalance, and dehydration. Findings: Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 8/18/23, indicated Resident 29 had weight loss of 5% or more in the last month or loss of 10% or more in the last six months. Resident 29 was not on a physician-prescribed weight-loss regimen. Resident 29 had diagnoses that included heart failure (e.g. congestive heart failure or CHF and pulmonary edema- a chronic condition in which the heart doesn't pump blood as well as it should) and diabetes mellitus (high blood sugar). Review of the weight and vital summary, dated 4/1/2023 through 11/30/2023, indicated Resident 29's weight record as follows: 4/2/23 - 89 lb 7/7/23 - 80 lb 10/1/23 - 75.9 lb 11/5/23 - 71.4 lb Review of the Nutrition/Dietary Notes dated 10/13/23, indicated Resident 29 has a significant…
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 · D2023-11-16 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 interviews and record review, the facility failed to ensure one (Resident 20) of five sampled residents was free from unnecessary drugs when the pharmacist's recommendation for reviewing the justifciation of the continued use of Benadryl (antihistamine/allergy) medication ordered PRN (as needed) was not acted upon. Definition: Benadryl is an antihistamine drug use for relief of allergic symptoms with warning that included central nervous depression which may impair physical or mental abilities, patient must be caution about performing tasks that required alertness}. Reference: https://online.[NAME].com. This failure had the potential for adverse medication side effects and not identifying other causes of itchy skin (dry skin, allergic reactions or other skin conditions). Findings: Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 9/27/23, indicated Resident 20 had diagnoses that included chronic lung disease. Resident 20 was on hospice (end-of life) 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 · F2022-03-01 · tag F0700 — widespreadTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to attempt to use alternatives, explain the risk and benefits and obtain informed consent from the resident and resident representative (RR) prior to installment of the bed side rails for 29 out of 29 residents (Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 30, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25). Also, there was no side-rail assessment conducted prior to initiation of the bed side rails for Resident 30. The facility's failure to assess bed side rail use for Resident 30 placed Resident 30 at risk for entrapment and injuries. Also, these failures resulted in 29 of 29 residents and their RR's to be unaware of risks and benefits of side rails and to be able to make an informed decision. [cross reference F835] Findings: During a record review of the facility's undated document titled, Half side rails list, it indicated all 29 residents residing at the facility had half side rails when in bed as enabler. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-03-01 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility's administration failed to identify, update and implement it's outdated policy and procedure for bed side rail use. The facility failed to administer bed side rails without reviewing risks and benefits; obtaining an informed consent from residents/ resident representatives; and without using less restrictive alternatives prior to installing bed side rails to 29 of 29 residents (Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 30, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25) residing at the facility. This failure placed all 29 residents residing at the facility at risk for avoidable injuries. [cross reference F700] Findings: During a record review of the facility's undated document titled, Half side rails list, it indicated all 29 residents residing at the facility had half side rails when in bed as enabler. During an observation on 2/22/22, at 11:15 a.m., bed side rails were up on both sides of the bed for all 29 residents residing at the facility. During another observation on 2/24/22, at 9:00…
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 · E2022-03-01 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat one of 12 sampled residents (Resident 27) with respect and dignity when: 1. Resident 27 had a clothing protector, commonly known as bib on for over three hours after breakfast hours; and 2. Registered Nurse (RN 1) addressed Resident 27 as [NAME] during incontinent care. These failures resulted in Resident 27 to not receive individualized care and had potential for Resident 27 to not feel respected. Findings: During a record review of Resident 27's admission Record dated 2/23/22, it indicated Resident 27 was admitted to the facility on [DATE]. During a record review of Resident 27's Annual Minimum Data Set (MDS- an assessment used to plan care) dated 1/27/22, the MDS assessment indicated, Resident 27's Brief Interview for Mental Status (BIMS- an assessment for cognition status) score was five (5) out of 15, indicating severe mental impairment. 1. During an observation on 2/22/22, at 10:03 a.m., Resident 27 was sitting in a wheelchair…
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 · E2022-03-01 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure privacy and confidentiality of medical information for two of two sampled residents (Residents 23 and 30) when: 1. Resident 30's electronic medical record was left exposed at Medication Cart 1; and 2. Certified Nursing Assistant 3 (CNA 3) did not provide privacy during toileting for Resident 23. These failures had the potential for unauthorized access to Resident 30's medical information and it violated resident's right to privacy for Resident 23. Findings: 1. During a concurrent observation and interview on 2/25/22, at 9:33 a.m., with Licensed Vocational Nurse 2 (LVN 2), the computer screen was observed open to Resident 30's medical record on Medication Cart 1. The computer screen was also observed exposing Resident 30's name, vital signs, physician name, allergy status, code status, photo, care plan, and pain assessment. LVN 2 stated Resident 30's record should have been secured when she stepped away from the cart. During an interview with the Director of Nursing (DON) on 2/25/22, at 9:48 a.m., the DON stated 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.
- Potential for harm · Ecited before2022-03-01 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a home like environment to five of 12 sampled residents (Resident 1, 23, 2, 8 and 30) when: 1. the room temperature for Resident 1 and 23 were too cold; and 2. the overbed tables for Residents 2, 8 and 30 were rough and unfurnished. The above failures resulted in Resident 1 and 23 feeling cold, and the potential for Residents 2, 8 and 30 getting scratched and hurting themselves. Findings: 1. A record review of Resident 1's admission Record dated 2/24/22, indicated Resident 1 was admitted on [DATE]. A record review of Resident 27's admission Record dated 2/25/22, indicated Resident 27 was admitted on [DATE]. During an interview on 2/22/22 1:02 p.m., Resident 1 stated that her room is always too cold, and she doesn't like it. During an observation and interview on 2/23/22, at 12:25 p.m., with the ADM (Administrator), the ADM stated the facility temperature is kept around 70ºF (degrees Fahrenheit). The ADM stated the nurses are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-01 · 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, record review, the facility failed to ensure its medication error rate did not exceed five percent for one of 12 sampled residents (Resident 27). There were four medication errors out of 25 opportunities resulting to 16 percent (%) medication error rate when Resident 27's percutaneous endoscopic gastrostomy tube (PEG tube, a feeding tube placed through the abdominal wall and into the stomach that allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth ) was not flushed (inserting a liquid substance into a tube, usually ) with water in between administering Apixaban (blood thinner medication), Ascorbic Acid (Vitamin C supplement), Doxazosin Mesylate (high blood pressure and urinary retention medications), and Vitamin D3 (Vitamin D supplement). This practice had the potential to jeopardize Resident 27' health, obstruct Resident 27's PEG tube, and cause unnecessary pain and discomfort to Resident 27. Findings: A record review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-01 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow the lunch menu for 12 of 12 sampled residents (Residents 31, 26, 28, 8, 2, 17, 24, 30, 20, 11, 5, 1, 19, 14 and 7) and the Dietary Department did not notify the residents of the menu change. This deficient practice resulted in Residents 31, 26, 28, 8, 2, 17, 24, 30, 20, 11, 5, 1, 19, 14 and 7 not knowing what food items they were getting for lunch and had the potential for residents not to get the nutritional value of the food item that was on originally on the menu. Findings: During a concurrent observation and interview on 2/22/22, at 11:52 a.m., with the Dietary Manager (DM), in the kitchen, it was observed that meatballs, spiral pasta and broccoli with other vegetables were being prepared. The DM stated the chicken was still frozen, they do not have broccoli, and he could not find the couscous. The DM stated he replaced the chicken with turkey meatball, replaced the broccoli with a broccoli mixed blend, and replaced the couscous…
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 before2022-03-01 · tag F0808 — failed to follow doctor-ordered diets — patternEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to follow the physician's order to provide a fortified diet (food that has extra nutrients added to it or has nutrients added that are not normally there) for two of 12 sampled residents (Residents 5 and 28). This deficient practice had the potential to cause Residents 5 and 28 to experience weight loss and to not meet or maintain their ideal body weight. Findings: During a concurrent observation and interview on 2/22/22, at 12:05 p.m., with the Dietary Manager (DM), Resident 5's meal tray on the kitchen cart was observed to not have any butter on it. The DM stated, they add butter to the plate for residents who have fortified diets. During a review of Resident 5's Order Summary Report, dated 2/25/22, the Order Summary Report indicated, Resident 5 was on a fortified diet. During an observation on 2/22/22, at 12:22 p.m., in Resident 28's room, Resident 28's lunch tray was observed on the overbed table with a diet card indicating Resident 28 was on a fortified diet. Resident 28's lunch tray was observed without…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-03-01 · 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, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. an opened lemon juice bottle, three turkey meat slices wrapped in foil, and one turkey pack with no open date were found in Refrigerator 2 (Ref 2), 2. one sliced banana in plastic wrap and five slices of oranges in an uncovered bowl with no prepared date were found in Refrigerator 1 (Ref 1), 3. one overripe banana was in Ref 1 and 11 overripe bananas was in the dry storage room, 4. Ref 1 had black crumbs on the door latch and had dried liquid drippings on Ref 1's back wall, 5. the can opener had dried matter and white hair stuck on it, 6. the dry storage area did not have a thermometer, 7. staff did not wash their hands and change gloves in between touching food items, handles, and their face mask; and 8. staff did not properly cover their hair with a hairnet. These failures placed the residents at risk for food borne illnesses. Findings: 1. During an initial tour of the kitchen with the Dietary Manager (DM) on 2/22/22,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-01 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to ensure the proper disposal and refuse of garbage when the trash bin inside the kitchen did not have its lid on for four hours, and the dumpster outside the facility was left open. This deficient practices had the potential to attract rodents and insects and cross-contamination of food. Findings: During an observation on 2/22/22, at 9:59 a.m., during the initial tour of the kitchen, a yellow trash bin near the dishwashing area had no lid on it. During an observation on 2/22/22, at 11:51 a.m., during tray line observation, a yellow trash bin was observed with no lid on it and the trash bin lid was tucked in between the trash bin and the wall. During an additional observation on 2/22/22, at 2:00 p.m., in the kitchen, the yellow trash bin lid was still observed with no lid on it. During a concurrent observation and interview on 2/23/22, at 6:59 a.m., with the Dietary Manager (DM), the dumpster outside the facility was observed open and the trash bin inside the kitchen was observed without a lid on it. The DM stated the trash bin…
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 · E2022-03-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their practices to maintain a clean and sanitary environment to prevent the spread of infections for five of 12 sampled residents (Resident 26, 16, 19, 25, and 27) when: 1. Resident 26 and 19's oxygen tubing was not dated and were observed on the floor and Resident 26's humidifier was not dated, 2. Resident 19's Foley catheter (a thin, sterile tube inserted into the bladder to drain urine) was laying on the floor; and 3. Registered Nurse 1 (RN 1) did not perform hand hygiene before preparing medications for Resident 25, 16, and 27. These deficient practices had the potential to expose Resident 26, 16, 19, 25, and 27 to possible infection. Findings: 1. During an observation on 2/22/22, at 11:00 a.m., in Resident 26's room, oxygen tubing was observed on the floor. The oxygen tubing and humidifier (a bottle that puts moisture into the air) were observed not having a date and time when it was changed. During an interview on 2/23/22, at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-01 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility to ensure kitchen equipment was maintained when the dishwasher temperature gauge (a device that measures the dishwasher temperature) did not measure the correct dishwasher water temperature. This deficient practice resulted in inaccurate measurements and documentation of dishwasher water temperatures and had the potential for dishes to not be cleaned and sanitized at the recommended temperature. Findings: During a concurrent observation and interview on 2/23/22, at 6:59 a.m., with the Dietary Manager (DM), in the kitchen, the dishwasher gauge was observed with the recommended temperature printed on its surface, which indicated 120 degrees Fahrenheit (F, a scale of temperature) minimum. The dishwasher gauge was observed registering water temperatures below the recommended temperature on three separate dishwashing cycles: 100 degrees F on the first cycle, 114 degrees F on the second cycle, and 116 degrees F on the third cycle. The DM stated the temperature of the dishwasher water should be at 120 degrees F. During an interview 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 · D2022-03-01 · 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 one of 12 sampled residents (Resident 23) received the necessary services to maintain personal hygiene when Resident 23 did not receive incontinent (inability to hold urine or bowels) care. This deficient practice had the potential to make Resident 23 feel the lack of dignity and respect. Findings: During an interview on 2/22/22, at 11:15 a.m., with Resident 23, Resident 23 stated, there was an incident during the night shift when Resident 23 called a certified nursing assistant (CNA) to help with emptying Resident 23's colostomy bag (a plastic bag that collects fecal matter from the digestive tract through an opening in the stomach wall called a stoma). Resident 23 further stated, the CNA came to the room, handed Resident 23 the bedpan and gloves, and the CNA left the room without assisting Resident 23 with emptying the colostomy bag. During an interview on 2/23/22, at 6:44 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated, Resident 23 usually calls at night to request staff help hold 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 · D2022-03-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to record and document one controlled medication (medication with potential or risk for abuse) when Norco (medication for severe pain) was not recorded and documented on the facility's Narcotics (a drug or substance that affects mood or behavior) Log for one of 12 sampled residents (Resident 26). This deficient practice had the potential for loss or diversion of Resident 26's pain medication. Findings: A record review of Resident 26's admission Record, dated 2/24/22, indicated Resident 26 was admitted on [DATE]. The admission Record also indicated Resident 26 had medical diagnoses including multiple fractures (broken bones) of ribs and a history of falls. A Record Review of Resident 26's Order Summary, dated 2/24/22, indicated Resident 26 had a physician's order, dated 2/2/22, for Norco Tablet 5-325 milligram (mg) one tablet by mouth two times a day for pain. During a concurrent observation, interview, and record review on 2/23/22, at 9:46…
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 before2024-10-10 · 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 one residents' room (room [ROOM NUMBER]) with multiple beds that provided less than 80 square foot (sq. ft) per resident who occupied this room. This failure 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 residents' belongings. Findings: During an observation on 10/8/24 at 12:14 p.m., in room [ROOM NUMBER], in the presence of Certified Nursing Assistant (CNA) 1, room [ROOM NUMBER]'s corresponding sq. ft per bed was identified: Room Floor Area 12 76.26 sq. ft During an observation on 10/8/24 at 12:14 p.m., room [ROOM NUMBER] had two beds with residents laid in bed awake and nonverbal. During a concurrent observation and interview on 10/8/24 at 12:15 p.m. with CNA 1 in room [ROOM NUMBER], CNA 1 stated there was enough space to conveniently provide care for residents in the rooms and for residents that needed Hoyer lift. CNA 1 stated bed was lowered and moved to use the Hoyer lift.…
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 before2022-03-01 · 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide one of one sampled resident in room [ROOM NUMBER] with at least 80 square feet per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for residents to have personal belongings at the bedside. After observation and interview, there was adequate space for the resident and staff to move about without obstruction. Recommend granting waiver. Findings: During a concurrent observation and interview, on 2/24/22 at 11:30 a.m., with the Administrator (ADM), room [ROOM NUMBER] was observed with two beds. The room measured 181.5 inches by 121 inches, with a total of 152.5 square feet. The ADM stated the room is below the standard of 80 square feet per resident and a double occupancy room should measure 160 square feet. There were no negative consequences attributable to the decreased space in room [ROOM NUMBER]; nor were any safety concerns noted.
“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. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2025-09-05 for 11 days
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| LEUNG, BELINDA | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2018 |
| LEUNG, KENNETH | Individual | CORPORATE DIRECTOR | since 01/01/2018 |
CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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. 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 055107. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-10, 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.