No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

San Leandro Healthcare Center

368 Juana Avenue, San Leandro, CA 94577 · For profit - Corporation · 62 certified beds · (510) 357-4015 Medicare & Medicaid certified

Call the home — (510) 357-4015 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 28 lower-level deficiencies on record (see below)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1300 Bancroft Ave · (510) 483-2600 · Call to confirm hours
Pharmacy
1550 E 14th St · (510) 483-0881 · Call to confirm hours
Grocery
1699 E 14th St · (510) 352-3337 · Call to confirm hours
Park
Veterans Memorial Building, 1105 Bancroft Ave · (510) 577-3462 · Typically dawn to dusk
Place of worship
1420 Santa Maria St · (510) 483-2132

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
Short-stay residentsrehab / post-hospital 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 held steady at 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.5%10.2%15.4%better
Long-stay residents who lose too much weight9.1%4.0%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection2.2%1.2%2.0%worse
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.1%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened12.8%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication1.5%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine97.2%98.2%95.3%typical
Long-stay residents with pressure ulcers3.8%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control6.3%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 table4.5%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine68.8%93.2%79.4%worse
Short-stay residents rehospitalized after admission23.8%23.0%22.6%typical
Short-stay residents with an outpatient ER visit19.7%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.092.251.67worse
Long-stay outpatient ER visits per 1,000 resident days5.381.571.80worse

* 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.

45.4% 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 150 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.4%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
71.0%U.S. median 56.6%
Met the expected recovery
0.34U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 71.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 69 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.4%CMS range 37.5–52.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 7.3–14.910.7%Oct 2022–Sep 2024no 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 discharge71.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge71.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge59.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting97.1%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 4.0–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.54
RN hours/ resident / day
0.91
LPN hours/ resident / day
2.69
Aide hours/ resident / day
4.14
Total nurse hours/ resident / day
0.37
RN hoursweekends
37.5%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 62 beds and averages 54.1 residents a day — about 87% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.14 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.69 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 3.77 hrs/resident/day on weekends vs 4.29 on weekdays — 12% thinner on weekends. RN hours go from 0.61 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

10
deficiencies at the latest standard inspection (2024-11-07)
10
at the previous standard inspection (2022-11-17)

Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Dcited before2026-06-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of three sample selected residents (Resident 1) was treated with respect and dignity, when the facility's staff talked to Resident 1 disrespectfully on two separate occasions as a reaction towards Resident 1's difficult behaviors towards direct care staff. This deficient practice resulted in Resident 1 feeling bad, disrespected and threatened.Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility in October 2021. During a review of Resident 1's Minimum Data Set (MDS, an assessment to plan and guide care) assessment dated [DATE], Section C - Cognitive Patterns indicated Resident 1's Brief Interview for Mental Status (BIMS, screening tool used by healthcare professionals to evaluate a person's memory, attention, and orientation) score was 15 of 15 (cognitive response and short-term memory are entirely intact). During an interview on 6/8/26 at 10:08 am., with 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-26 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 was treated with respect and dignity when Certified Nursing Assistant (CNA) 1 loudly argued with Resident 1.This failure had resulted in Resident 1's emotional distress. During a review of Resident 1's admission Record (AR) dated 11/18/25, the AR indicated Resident 1 was admitted to the facility in August 2025 with diagnoses that included major depressive disorder (a mental health condition causing persistent sadness, hopelessness, and loss of interest in activities, significantly impacting daily life) and post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event, such as combat, assault, or a natural disaster).During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) assessment dated [DATE], the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-26 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    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, for one of two sampled residents (Resident 2), the facility failed to ensure Resident 2 was afforded the right to participate in the care planning process when care conference meeting was not scheduled despite repeated requests from Resident 2's representative.This failure had the potential to result in Resident 2 being uninformed about treatment objectives and care plan.During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility in March 2025 with diagnoses that included cognitive communication deficit (a difficulty with communication caused by impairments in cognitive functions like memory, attention, and problem-solving, rather than by problems with speech or language), age-related cognitive decline (a natural slowdown in thinking and memory that occurs with aging), and epilepsy (a brain disorder characterized by recurrent seizures, which are temporary disruptions in brain activity). The AR also indicated 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-07 · tag F0847 — pattern
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    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 verify that residents understood binding arbitration agreements (a formal method of dispute resolution where a third party makes a decision instead of the dispute going to court) and/or that they were aware they could rescind the agreement within 30 days for 3 of 3 sampled residents (Resident 18, Resident 13, and Resident 49). This failure had the potential for residents to enter into an agreement without understanding their rights. Findings: During a review of the arbitration agreement made between the facility and three randomly selected residents (Resident 18, Resident 13, and Resident 49), the arbitration agreements included three boxes stating prior to signing this agreement the resident reviewed the voluntary arbitration program guide, the resident received a copy of this agreement after it's execution, and the resident is aware that he/she may rescind the agreement in writing at any time within thirty (30) days of the date of its…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-07 · tag F0848 — pattern
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide a binding arbitration agreement (a formal method of dispute resolution where a third party makes a decision instead of the dispute going to court) that met the regulations. This failure had the potential for residents to enter into an agreement that did not protect their rights. Findings: During a review of the arbitration agreement made between the facility and three randomly selected residents (Resident 18, Resident 13, and Resident 49), the arbitration agreement for all three residents did not provide for the selection of a neutral arbitrator agreed upon by both parties and/or provide for the selection of a venue that is convenient to both parties. During a concurrent interview and record review on 11/6/24 at 1:55 p.m. with Administrator (ADM), Resident 49's arbitration agreement, dated 9/28/24, Resident 18's arbitration agreement, dated 9/24/24, and Resident 13's arbitration agreement, dated 8/7/24, were reviewed. ADM stated the documents do not have a section that provides for the selection of 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide clean and comfortable home like environment for 4 residents residing in two of 25 rooms in the facility when the shared bathroom in these 2 rooms had a towel on the floor and the toilet seat was dirty with brown particles on the toilet seat. This failure placed all 4 residents residing in these rooms at increased risk for healthcare-associated infections (HAIs), which could result in longer recovery times, additional medical treatments, and even hospitalizations and negatively impact the residents' overall well-being and quality of life. Findings: During a concurrent observation and interview on 11/4/24 at 10:14 a.m. with the Social Worker (SW), the shared bathroom between room [ROOM NUMBER] and 21 was observed. A towel was on the floor and the toilet seat was dirty with brown particles on the toilet seat. SW confirmed the toilet seat was not clean, with brown particles and towel on the floor, and stated the bathroom should always kept clean 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0640 — isolated
    Encode 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 complete and transmit Discharge Minimum Data Set (MDS, an assessment tool to guide patient care) for one of one sampled resident (Resident 11) to Centers of Medicare and Medicaid Services (CMS) for over 120 days. This failure resulted in reflecting Resident 11 as an active resident while he was already discharged from the facility. Findings: During a review of Resident 11's admission Record (a record with residents' basic information) printed on 11/6/24, the record indicated Resident 11 was admitted to the facility in June 2024. During a concurrent interview and record review on 11/6/24 at 12:53 p.m. with the MDS Coordinator (MDSC), Resident 11's progress notes dated 7/12/24 was reviewed. The MDSC stated Resident 11 was discharged from the facility on 7/12/24. MDSC stated facility was required to complete a Discharge MDS Assessment upon residents' discharge from the facility. The MDSC stated, Resident 11's discharge MDS was not completed and/or transmitted to CMS till date. A review of the CMS guide,Resident Assessment…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately assess and code active diagnosis for one of 21 sampled residents (Resident 31) in the admission Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) assessment when Resident 31's admission MDS assessment was inaccurately coded with a Yes for diagnoses of Pneumonia (an infection of one or both lungs caused by bacteria, viruses or fungi causing difficulty in breathing, cough, fever, and chills) and Septicemia (a life-threatening blood infection) during the look back period). During this period, Resident 31 did not have active Pneumonia and Septicemia. This failure resulted in an outdated and inaccurate reflection of Resident 31's medical/clinical status. Findings: During a review of Resident 31's admission Record (a record with residents' basic information) printed on 11/6/24, the record indicated Resident 31 was admitted to the facility in…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 interview and record review, for one of five sampled residents (Resident 17) reviewed for activities of daily living (ADL) care, the facility failed to implement a comprehensive-centered ADL plan of care. This failure had the potential to result in delayed provision of care. Findings: During a review of Resident 17's admission Record, the admission Record indicated, Resident 17 was admitted to the facility in February 2024 with diagnoses that included morbid obesity, acute and chronic respiratory failure (acute or chronic impairment of gas exchange between the lungs and the blood), chronic pain syndrome, paraplegia (the loss of muscle function in the lower part of the body including both legs), and pain in left knee. During a review of Resident 17's Minimum Data Set (MDS, an assessment tool used to direct resident care) assessment dated [DATE] indicated Resident 17 had impairment on both lower extremities and totally dependent on staff for toileting hygiene (ability to maintain perineal hygiene, adjust…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 and record review the facility failed to provide Activities of Daily Living (ADL) for one of 17 sample selected residents (Resident 157), when Resident 157 was observed with long, broken finger nails and black particles under nails. This failure placed Resident 157 at risk for skin damage and infection and also affect his comfort and dignity, contributing to a lower quality of life and possible emotional distress. Findings: A review of Resident 157's admission Record indicated, Resident 157 was admitted to the facility with multiple disease including Cerebral Palsy (a group of neurological disorders that affect a person's ability to move, balance, and maintain posture). During an observation on 11/4/24 at 12:00 p.m. inside Resident 157's room, Resident 157 was observed with long finger nails, with broken and black particles under the nails. During an interview on 11/4/24 at 2:30 p.m. with Certified Nurse Assistant (CNA) 2, CNA 2 confirmed the long , broken and black particles under Resident 157's finger nails and stated the licensed nurses did not ask him to cut…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Dcited before2024-11-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the observation, interview and record review, the facility failed to safely administer and provide adequate supervision to one of 21 sampled residents (Resident 18) while using a hot water bag (a rubber container designed to hold hot water to apply warmth to specific areas of the body) on her body to keep herself warm for over 24 hours. This failure placed Resident 18 at risk for skin burns. Findings: During a review of Resident 18's admission Record (a record with residents' basic information) printed on 11/4/24, the record indicated Resident 18 was admitted to the facility in Septembet 2024. During a record review of Resident 18's Minimum Data Set (MDS, an assessment used to guide care) dated 9/30/24, the assessment indicated Resident 18 had an active diagnosis of Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). The assessment indicated Resident 18's Brief Interview for Mental Status (BIMS, an assessment tool used to screen and identify memory, orientation, and judgement status of the resident) score was 15 out of 15, indicating…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to establish a system of disposition of controlled drugs for accurate reconciliation when blister packs (also called a bubble pack, blister pack, a card that packages doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles [or blisters] and each pack is secured by a strong, paper-backed foil that protects the pills until dispensed) of controlled medications with popped and taped shut blisters were stored. This failure had the potential to result in inaccurate reconciliation of controlled medications. Findings: 1. During an observation and concurrent interview and review on 11/4/24 between 1:41 p.m. and 2:19 p.m. with Licensed Vocational Nurse (LVN) 2, Station 1 medication cart was observed. Inside the medication cart narcotic (controlled) box was a blister pack of oxycodone hydrochloride (controlled pain medication/narcotic) 5 milligrams (mg) had two blisters, individual blister #7 count and # 8, that were popped and taped shut with a paper tape. The blister pack was inside…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-12 · tag F0624 — isolated
    Prepare residents for a safe transfer or discharge from the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three discharged residents (Resident 1) had a safe and appropriate discharge location based on his medical needs when Resident 1 who was legally blind was discharged to an independent living facility where resident sustained falls. This failure placed Resident 1 at risk for adverse health outcomes that had the potential to cause serious complications and psychosocial harm. Findings: During a review of Resident 1's admission record, printed on 9/12/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and has a medical diagnosis including history of cerebral infarction (a condition which occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) without residual deficits, generalized muscle weakness and need for assistance with personal care. During a record review of Resident 1's Minimum Data Set (MDS, a 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-11-17 · tag F0800 — widespread
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    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 37 out of 37 residents with regular diet received enough protein on a regular basis. This practice failure had a potential of malnutrition and protein deficiency for 37 residents on regular diet who were residing at the facility. Findings: During a concurrent observation and interview on 11/15/22 at 11:30 a.m., in the kitchen with Dietary Manager (DM), staff prepared dishes to serve residents with regular diet, fish was measured by the facility's scale and the weight of the fish was 2.1 oz (ounce, measurement) instead of 3 oz for regular diet. DM stated it was important to follow the protein measurements in the recipes because residents could have malnutrition or lose weight. DM stated she had no idea she had to follow the recipe for cooking size. DM confirmed 37 residents were on a regular diet at that time. During an interview and record review on 11/16/22 at 9:30 a.m., with Dietitian (D), D reviewed the recipe and stated kitchen staff had to use 4 oz fish for cooking and serving size should be 3 oz.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-17 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure two of two sample selected non-English speaking residents (Resident 108 and 110) had an appropriate communication system in place when Residents 108 and 110 did not have a written translation of vital information (communication board) at the bed side. This failed practice resulted in Residents 108 and 110 not being able to communicate effectively with staff and to express their needs. Findings: A review of Resident 108's admission Record indicated Resident 108 was admitted to the facility with diagnosis of Hepatic encephalopathy (syndrome of impaired brain function occurring in patients with advanced liver diseases). During an observation and interview on 11/14/22 at 2:00 p.m., at Resident 108's room with Certified Nurse Assistant (CNA) 2, Resident 108 was observed not able to talk in English with the surveyor. CNA 2 confirmed Resident 108 was Spanish speaking and staff used sign language to communicate with Resident 108. CNA 2 was not able to find a communication board at Resident 108's bedside and did…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    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 its policies and procedures for oxygen administration and ensure oxygen supplies were maintained according to the operator's manual for three (Resident 39, 5, and 20) of four sampled residents receiving oxygen therapy, when staff did not document oxygen flow and rationale of Resident 39's oxygen therapy and Resident 39, 5, and 20's oxygen concentrator (an electronically operated device that separates oxygen from room air and provides high concentration of oxygen directly through a nasal cannula, a lightweight tube with one end split into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) filter was covered with a thick layer of gray, fluffy matter. This deficient practice had the potential for Resident 39, 5 and 20 to receive ineffective and inadequate oxygen therapy. Findings: A review of Resident 39's admission Record dated 11/17/22 indicated Resident 39 was admitted to the facility 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-11-17 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure pharmacy medication cart storage were clean and orderly, when various items were found in the narcotic box of Medication Cart (Med Cart) 1 and 2, and loose pills were found in Med Cart 1. This deficiency had the potential to result in medication diversion. Findings: During an inspection of Med Cart 2 on 11/16/22 at 11:20 a.m., the narcotic box had a plastic container which had a dirty wallet labeled with a resident's name, several loose coins, keys in a key ring, dollar bills, a cell phone, hearing aids and batteries, two wrist watches and a bag with 22 empty small medicine bottles. During an interview on 11/16/22 at 11:35 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated only narcotic medications were supposed to be in the narcotic box. During a concurrent inspection of Med Cart 1 on 11/16/22 at 12:50 p.m. and interview with LVN 3, the narcotic box had a plastic container with three pairs of hearing aids, a ring, a necklace, coins, and several letter envelopes which contained dollar bills. LVN…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-17 · tag F0838 — failed to assess facility resources and resident needs — pattern
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    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 obtain contracts, memorandum of understanding, or other agreements with third parties to provide dialysis services for three of four sampled residents (Resident 4, 43, 28) who were receiving dialysis treatments (the process of removing excess water, impurities from the blood of people whose kidneys could no longer perform these functions normally). This failure had the potential for Resident 4, 43, and 28 to receive inadequate or inappropriate dialysis care. Findings: A review of Resident 4's admission record dated 11/15/22 indicated Resident 4 was admitted to the facility on [DATE] with end stage renal disease (a medical condition in which a person's kidneys stop functioning on a permanent basis, leading to the need for dialysis or a kidney transplant), and dependence on renal dialysis. A review of Resident 4's order summary report dated 11/16/22 indicated Resident 4 was scheduled for dialysis at Dialysis Center 1 on Monday, Wednesday,…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-11-17 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure infection control policies and procedures were followed for one (Resident 39) of three sampled residents when: 1. Certified Nursing Assistant 1 (CNA 1) did not wear a gown while providing care for Resident 39 and CNA 1 did not perform hand hygiene after removing soiled incontinent briefs and applying clean briefs to Resident 39; 2. Resident 39's foley catheter (a thin, flexible tube placed in the bladder to drain urine) tubing was touching the floor; and 3. Resident 39's room did not have a dedicated PPE trash bin. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff. Findings: 1. During a review of Resident 39's admission record, printed 11/17/22, the admission record indicated Resident 39 was originally admitted to the facility on [DATE] with VRE Infection (Vancomycin- Resistant Enterococci - can cause infections of the urinary tract, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-17 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain the privacy for one (Resident 34) of 14 sampled residents when staff did not pull the privacy curtain when giving Resident 34 a bed bath. This deficient practice resulted in Resident 34 feeling his privacy was not honored. Findings: A review of Resident 34's admission Record dated 11/17/22 indicated Resident 34 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (a symptom that involves one-sided paralysis). A review of Resident 34's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 9/9/22 indicated Resident 34 was cognitively intact and required total dependence on one staff to bathe. During a concurrent observation and interview on 11/15/22 at 11:34 a.m. in Resident 34's shared room, Resident 34 was receiving a bed bath from Certified Nursing Assistant (CNA) 1. The privacy curtain was not pulled around to provide privacy and Resident 34 was fully exposed. Resident 34 can be seen by his…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-17 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure to inform the ombudsman (an official appointed to investigate individuals' complaints against maladministration, especially that of public authorities) for one of three sample selected discharged residents (Resident 54) when, Resident 54 left the facility unplanned after signing an AMA (leaving Against Medical Advice). This failure practice had the potential for Resident 54 to be in an unsafe environment and not have access to medical intervention. Findings: A review of Resident 54's admission Record indicated Resident 54 was admitted to the facility on [DATE] with diagnosis of congestive heart failure (heart muscle does not pump blood as well as it should). During an interview on 11/17/22 at 10:02 a.m., with the Director of Nursing (DON), DON stated Resident 54 left the faciity on 9/20/22 unplanned when Resident 54's friend picked him up. DON stated Resident 54 signed the AMA form. DON further stated when residents leave the facility AMA, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an environment that was free from accidents for one (Resident 39) of one sample resident when the facility did not implement interventions to reduce the risk for falls for Resident 39 who had a history of frequent falls. This deficient practice had the potential for Resident 39 to experience a fall. Findings: A review of Resident 39's admission Record dated 11/17/22 indicated Resident 39 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing low levels of oxygen in your body tissues). A review of Resident 39's Minimum Data Set (MDS, a tool to guide resident care) dated 4/30/22, indicated Resident 39 had one fall with no injury, one fall with injury and one major fall since admission. A review of Resident 39's Morse Fall Scale (a method of assessing a patient's likelihood of falling) indicated Resident 39 was at high risk…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-03-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow proper food handling practices when a dietary staff member during trayline (a system of food preparation in which trays move along an assembly line) did not change gloves and wash her hands after she opened two cabinet drawers while wearing gloves and then returned to trayline. This deficient practice had the potential to result foodbourne illness. Findings: During an observation of trayline on 3/27/19, at 11:54 a.m., [NAME] (CK) 1 stopped doing trayline, opened two cabinet drawers and removed clean utensils from the drawers. CK 1 then returned to trayline, and continued to handle clean plates, serving utensils and food. CK 1 did not remove her gloves and wash her hands between opening the cabinet drawers and returning to trayline. During an interview with CK 1 on 3/27/19, at 11:57 a.m., CK 1 stated she should have removed gloves and washed hands after touching cabinet drawers and before returning to trayline. During an interview with the Dietary Supervisor (DS) on 3/27/19, at 11:59 a.m., DS stated…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-03-28 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, for two of 17 sampled residents (Resident 188 and 3) the facility failed to ensure food was served under sanitary conditions when Rehabilitation Nurse Assistant (RNA) 1 did not perform hand hygiene (wash hands with soap and water or use an alcohol based hand rub) while serving meals to Residents 188 and 3 and [NAME] (CK) 2 attempted to store a tray of food that was previously placed on Resident 3's overbed table. For Resident 188 and Resident 3, this deficient practice had the potential to result foodborne illness. Findings: During an observation on 3/26/19, at 11:58 a.m., RNA 1 passed trays to residents without having first performed hand hygiene. RNA 1 spilled salad dressing on her hand, dumped the salad dressing from her hand onto Resident 188's salad, and then continued to serve food to other residents. RNA 1 then left the dining area without performing hand hygiene and assisted other staff with delivering trays of food to residents in their room. In a joint interview on 3/28/19, at 9:17 a.m., the Director of Staff Development…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-03-28 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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, for two (Resident 20 and 28) of 17 sampled residents the facility failed to maintain the privacy of personal care information when signs indicating personal care instructions for Residents 20 and 28 were posted in locations visible to other residents and visitors. This failure had the potential to result in Resident 20's and Resident 28's personal care information to be viewed by other residents and visitors. Findings: 1. Review of Resident 28's admission Record, printed 3/15/19, indicated Resident 28 was admitted to the facility on [DATE]. During an observation on 3/26/19 at 8 a.m., there was a sign that indicated swallowing guidelines and speech therapy instructions for Resident 20 which was posted above her bed and was viewable from the hallway. During an interview with Licensed Vocational Nurse (LVN) 1 on 3/27/19, at 7:57 a.m., LVN 1 stated Resident 28's care instructions that were posted above her bed needed to be covered to maintain Resident 20's privacy.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2024-11-07 · tag F0912 — pattern
    Provide 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 18 rooms (Rooms 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25) 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. After observation and interview, there was adequate space for residents and staff to move about without obstruction. Recommend granting waiver. Findings: During an interview with the Administrator (ADM) on 11/06/24 at 12:50 p.m., the following rooms and corresponding square footage per bed were identified: Room Activity Room Size Floor Area 7 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed 8 Bedroom [ROOM NUMBER] sq ft 70 sq.ft/bed 9 Bedroom [ROOM NUMBER] sq ft 70 sq.ft/bed 10 Bedroom [ROOM NUMBER] sq ft 70 sq.ft/bed 11 Bedroom [ROOM NUMBER] sq ft 72 sq.ft/bed 12 Bedroom [ROOM NUMBER] sq ft 73…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2022-11-17 · tag F0912 — pattern
    Provide 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 18 rooms (Rooms 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25) 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. After observation and interview, there was adequate space for residents and staff to move about without obstruction. Recommend granting waiver. Findings: During an interview with the Assistant Administrator (AA) 1 on 11/14/22 at 1:00 p.m., the following rooms and corresponding square footage per bed were identified: Room Activity Room Size Floor Area 7 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed 8 Bedroom [ROOM NUMBER] sq ft 70 sq.ft/bed 9 Bedroom [ROOM NUMBER] sq ft 70 sq.ft/bed 10 Bedroom [ROOM NUMBER] sq ft 70 sq.ft/bed 11 Bedroom [ROOM NUMBER] sq ft 72 sq.ft/bed 12 Bedroom [ROOM NUMBER] sq…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2019-03-28 · tag F0912 — pattern
    Provide 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 record review, the facility had 18 resident (Rt) rooms (7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied these rooms. This failure had the potential to result in inadequate space for the delivery of care to each of the resident in each room, or for storage of the residents' belongings. Findings: During an observation on 3/26/19 at 8 a.m., the following sq.ft. were identified: Room Activity Room Size Floor Area 7 Rt room [ROOM NUMBER].68 sq.ft 71.42 sq.ft/bed 8 Rt room [ROOM NUMBER].03 sq.ft 70.25 sq.ft/bed 9 Rt room [ROOM NUMBER].03 sq.ft 70.25 sq.ft/bed 10 Rt room [ROOM NUMBER].56 sq.ft 70.14 sq.ft/bed 11 Rt room [ROOM NUMBER].31 sq.ft 72.15 sq.ft/bed 12 Rt room [ROOM NUMBER].60 sq.ft 72.94 sq.ft/bed 14 Rt room [ROOM NUMBER].60 sq.ft 72.94 sq.ft/bed 15 Rt room [ROOM NUMBER].39 sq.ft 73.19 sq.ft/bed 16 Rt room [ROOM NUMBER].39 sq.ft 73.19 sq.ft/bed 17 Rt room [ROOM NUMBER].39…

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

    Environmental Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PRATAP PODDATOORI — 6 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 →

RatingThis homeChain avg
Overall 4 of 53.5+0.5 vs chain
Health inspection 4 of 53.2+0.8 vs chain
Staffing 4 of 53.8+0.2 vs chain
Quality measures 4 of 54.2-0.2 vs chain
The other 5 homes this chain runs (chain average 3.5★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
PODDATOORI, PRATAPIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 05/13/2003
HYCARE INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/07/2006
ALCANTARA, CHERYLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2009
ANDRES, NORMAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2004
CORTEZ, CARLOSIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/09/2024
DHUGGA, GURPREETIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/16/2019
EHRENFELD, MARIANNEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/16/2023
GUERRERO, SYLVIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2022
KAKKAR, KANIKAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/25/2023
LOPEZ, LUCILLAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2016
MADAMBA, LARAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/25/2023
MCGREGOR, TERRANCEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2003
PADANIA, HILDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/16/2025
TAMONDONG, CONSUELOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2013
TRAN, VYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/18/2024
WYNNE, PORSHIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/16/2023

CMS files one row per role, so the 34 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$11.0M
Net patient revenuemost recent cost report
+10.3%
Operating marginrevenue minus expenses
$1.2M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 22%Other / private 21%

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$502per resident / day
operating cost
$15,267per month
≈ monthly operating cost
$560per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 056345. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-07, 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.

What to do next