San Luis Post Acute Center
3033 Augusta Street, San Luis Obispo, CA 93401 · For profit - Corporation · 162 certified beds · (805) 544-5100 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 19% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.5% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.9% | 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 | 1.3% | 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 | 0.4% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 4.9% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.3% | 13.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.7% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 7.2% | 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 | 25.7% | 12.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 12.9% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 15.2% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.86 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.54 | 1.57 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
66.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 273 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.4% 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 131 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% 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 | 66.7%CMS range 61.7–71.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 7.9%CMS range 5.7–10.6 | 10.7% | Oct 2022–Sep 2024 | better than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 53.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 46.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 54.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 4.8%CMS range 3.0–8.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 162 beds and averages 88.2 residents a day — about 54% occupied, or roughly 74 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.44 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.95 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.08 hrs/resident/day on weekends vs 4.59 on weekdays — 11% thinner on weekends. RN hours go from 0.56 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · Dcited before2025-11-13 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan with resident-specific interventions for 1 of 3 sampled residents (Resident 1) related to non-compliance with care and refusal to wear protective foam boots (designed to protect patient's feet-heels, ankles).This failure resulted in the development of maggots in the dorsal (upper side) wound of Resident 1's left foot and was transferred to the hospital for further evaluation and treatment. During a concurrent interview and record review, on 9/24/25, at 11:24 a.m. with the Director of Nursing (DON), the DON stated, The resident (Resident 1) was admitted on [DATE] with 10 plus wounds. All were pre-existing wounds upon admission. Resident 1's History and Physical dated 9/3/25, revealed Resident 1 was admitted to the facility on [DATE]. Diagnoses included PAD (Peripheral Artery Disease [a condition where arteries that carry blood to the arms, legs, and feet become narrow or blocked]) with associated chronic venous stasis (condition…
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 · D2025-03-13 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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's interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to conduct an assessment of self-administration of medications, obtain a doctor's order, and ensure a care plan was developed for one of 5 sampled residents (Resident 30). This failure had the potential to increase the risk for medication errors which could compromise the safety and well-being of Resident 30. Findings: Resident 30 is a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included unspecified asthma with acute exacerbation (a sudden worsening of asthma symptoms, where the specific type of asthma is not specified, requiring immediate medical attention). On 3/10/25 at 10:15 a.m., in room [ROOM NUMBER], Resident 30 was observed holding in her hand, an inhaler medication. Resident 30 stated that she was a retired physician and aware of how 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 · Dcited before2025-03-13 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety when: 1. The nourishment refrigerator that contained multiple food items had a temperature of 46 degrees 2. A boxed food item that was stored in the freezer had an expired date. This failure had the potential to result in the growth of microorganisms that can cause foodborne illness to 66 residents admitted to the facility. Findings: 1. During an observation of the Station 1 nourishment room refrigerator on 3/12/25 at 1:59 p.m., there were two thermometers located inside the refrigerator that showed the temperature was 42 degrees Fahrenheit (F). The refrigerator contained sandwiches, yogurts and milk. The yogurt dated 3/10/25, temperature was 46 degrees F. The low-fat milk was 46.2 degrees F. At 2:00 p.m. a concurrent observation and interview was conducted with the Social Services Director (SSD), confirmed and validated the temperature of the milk. During a concurrent observation and interview on 03/12/25 at 2:01 p.m.,…
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 before2025-03-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure staff followed proper hand hygiene during direct resident contact for one of 18 sampled residents. This failure had the potential to result in the spread of infectious disease throughout the facility. Findings: During an observation on 3/12/25 at 10:05 a.m., in resident room, Licensed Nurse (LN) 2 was observed performing a brief change for Resident 18. LN2 cleaned stool from Resident 18's buttocks and rolled Resident 18 onto the right side while wearing the same soiled gloves. LN2 did not perform hand hygiene or change gloves prior to touching resident. During an interview on 3/12/25 at 10:40 a.m., with LN2, LN2 stated, I know I should have changed my gloves. I wiped her poop. During an interview on 3/13/25 at 9:45 a.m., with Director of Staff Development (DSD), Assistant Director of Nursing (ADON), both were informed that during an interview with LN2, LN2 stated she was aware that she should have changed her soiled glove after she completed the brief change but she did not. DSD stated LN2 will complete…
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 · D2025-03-13 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, nd record review the facility failed to ensure the walk-in freezer was maintained in a safe operating condition. There was excessive ice buildup in the freezer. This failure had the potential to result in reduced efficiency and temperature fluctuations that can lead to improper food preservation. The facility census was 66. Findings: During an initial kitchen tour that started on 3/10/25 at 10:17 a.m., the following were observed: ice buildup on different areas and surfaces including the freezer pipes (approximately 6 inches by 3 inches and 2-inch-deep of ice), the plastic air curtains hanging in the doorway contained ice buildup approximately half to three quarters of the way down the curtain flaps. On the shelf under the fans, two different areas with ice on the shelf below approximately two inches in length. The second area was approximately eight inches in length. Around the door and gasket, there was ice buildup with the width of the doorway. The freezer door on the outside at bottom there was also ice buildup. During an interview on 3/11/25 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 · Fcited before2024-01-18 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, facility policy review, and review of facility documents, the facility failed to ensure all potential sources of water-borne illness were identified and monitored. This deficient practice affected all 65 residents who currently reside in the facility. Findings included: A review of the facility's undated policy titled, Legionella Water Management and Risk Reduction and Prevention Program, revealed, Our facility is committed to the prevention, detections and control of water-borne contaminants, including Legionella. The policy specified, 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria could grow and spread, and to reduce the risks of Legionnaire's disease [a type of pneumonia caused by Legionella bacteria]. A review of the facility Legionella Prevention Program Maintenance Log, revealed no evidence to indicate the facility monitored the bathtubs in the facility, the water fountains, the laundry area, or the kitchen dishwasher. During an interview on 01/18/2024 at 11:01 AM, the Maintenance…
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 · D2024-01-18 · 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 interviews, record review, and document review, the facility failed to notify the state designated authority when a significant change in status assessment was completed for 1 (Resident #7) of 2 sampled residents reviewed for preadmission screening and resident review (PASARR). Findings included: A review of Resident #7's Face Sheet, revealed the facility admitted the resident on 06/01/2009, with diagnoses of malignant neoplasm of colon, anxiety, psychotic disorder with hallucinations, and major depressive disorder. A review of a document addressed to Resident #7 from the State of California - Health and Human Services Agency Department of Health Care Services, dated 01/28/2019, revealed Resident #7's Level II PASARR evaluation suggested the resident was best served in a skilled nursing facility bed with access to services. A review of Resident #7's medical record revealed a significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2023, was signed as being completed on 12/26/2023. A review of Resident #7's medical record revealed…
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 · D2021-05-14 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based record review and interview, the facility failed to obtain informed consent for an increased dose of a psychotropic medication (Seroquel) prior to administration for one out of 24 sampled residents, (Resident 31). This failure had the potential for the responsible party to be uninformed of the risks and benefits of the medication. Findings: Review of the facility policy and procedure titled Right To Be Informed/Make Treatment Decisions dated 3/18/2018 indicated the right to be informed in advance, by the physician or other practitioner or professional of the risk and benefits of proposed care, of treatment alternatives or treatment options and to choose the alternative or options he or she prefers. During a concurrent record review and interview on 5/14/2021 at 10:45 a.m., with the assistant director of nursing (ADON), the document titled Physician Orders dated 5/7/21, indicated in part . Seroquel (an antipsychotic medication) increased to 75mg . for Resident 31. Further review of Resident 31's electronic health record (EHR) did not contain a signed informed consent for this…
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 · D2021-05-14 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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
Based on interview and record review the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST-a care directive during life threatening situations) matched the electronic medical record (EMR) in one of 24 sampled residents (Resident 16), This facility failure had the potential to cause a delay in receiving or incorrectly administering life-sustaining treatments. Findings: During a concurrent interview and record review on 5/12/21, at 12:11 p.m., with the director of nursing (DON), Resident 16's POLST was reviewed. The POLST indicated do not attempt resuscitation (DNR), selective treatment IV (in the vein) fluids, IV antibiotics, do not intubate and a trial period of artificial nutrition including feeding tubes. Resident 16's Physician Orders in the EMR were reviewed. The physician orders indicated DNR and comfort measures only. The physician orders did not indicate a trial period of artificial nutrition. The DON agreed the records did not match. The DON indicated the physician order in the EMR was changed on 11/11/19 discontinuing the trial period of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-14 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care) was accurate for two of 24 sampled residents (Resident 14 and Resident 17) when: 1. The dental assessment of Resident 14's broken and missing teeth was not reflected on the MDS. 2. Resident 17's neurological status of Traumatic Brain Injury (TBI) was left blank. These failures had the potential to result in Resident 14's and 17's identified care needs to go unmet. Findings: 1. During a concurrent observation and interview on 5/11/21, at 11:55 a.m., with Resident 14, Resident 14 indicated having right upper tooth pain. The tooth was observed to be yellow/brown in color and also noted were several missing teeth. Resident 14 further indicated x-rays of teeth was performed ,the tooth needed to be extracted and causes pain when eating. During a review of Resident 14's Dental Care evaluation form dated 3/2/20, the evaluation indicated, Resident 14 had multiple missing teeth and many cavities that are not restorable.…
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 6 citations
- Potential for harm · Dcited before2021-05-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interview, the facility failed to develop and implement a comprehensive care plan for one of 24 sampled residents (Resident 32). This facility failure had the potential for Resident 32's dental care needs to not be met. Findings: During a review of Resident 32's dental consult titled Onsite Skilled Dental Care dated 3/2/20, indicated Pt (Resident 32) refuses Tx (treatment) .multiple missing teeth. The document further indicated Resident 32's cooperation and motivation for dental services was Poor/Negative. During a review of Resident 32's Onsite Dental Visit Summary dated 4/8/21, indicated that Resident 32 Refused X-Ray. During a review of Resident 32's Dietary Progress Notes dated 4/21/21, indicated the registered dietician (RD 1) spoke with Resident 32. The progress notes indicated RD 1 Spoke with resident (Resident 32) regarding request to change diet due to oral pain. During a review of Resident 32's dental consult titled Onsite Skilled Dental Care dated 5/3/21, indicated Resident 32's cooperation and motivation for dental services was Poor/Negative.…
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 · D2021-05-14 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain an order prior to the administration of oxygen for one of 24 sampled residents (Resident 31). This failure had the potential for Resident 31 to suffer complications from incorrect dosage of oxygen administration. Findings: According to [NAME] and Perry's Fundamentals of Nursing, Eighth Edition, page 336, Nurses follow physicians orders unless they believe the orders are in error or harm clients. During an initial tour on 5/11/2021 at 2:43 p.m., Resident 31 was observed lying in bed with a nasal cannula (a device placed in the nose to deliver oxygen), connected to an oxygen concentrator administering 2 liters per minute of oxygen. During a review of Resident 31's clinical record on 5/13/2021 at 2:20 p.m., no physician order for oxygen administration was located. During an interview on 5/13/2021 at 2:25 p.m. with a licensed nurse (LN2), LN2 indicated Resident 31 is on 2 liters of oxygen via nasal cannula. LN2 agreed there was no…
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 · D2021-05-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a nasal cannula and tubing (a device used to deliver supplemental oxygen or increased airflow to a patient) was secured in the designated storage bag for one sampled resident, (Resident 25). This failure had the potential for increased risk of infection due to improper storage of the nasal canula and tubing. Findings: During a concurrent observation and interview on 5/11/21, at 3:03 P.M with a Certified Nursing Assistant (CNA 1), in Resident 25's room, the nasal cannula tubing was hanging over the side rail of the bed. CNA 1 stated, This (pointing to the nasal cannula and tubing) should be in this bag (pointing to the storage bag hanging on the oxygen concentrator). During a concurrent observation and interview on 5/14/21, at 9:06 A.M., with a Student Nursing Assistant (SNA 1), in Resident 25's room, observed nasal cannula and tubing wrapped over the side rail of the bed. SNA 1 confirmed this stating, Yes, it is. Would you like me to put it in the bag? During a review of the facility's policy and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-14 · 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
Based on observation, interview, and record review, the facility failed to ensure : 1. A medication cart and medication storage closet were free from expired medications. This failure had the potential to result in residents receiving expired medications (drugs which are past their shelf life can decompose and either be ineffective or even harmful). 2. Tube feeding formula and tubing were labeled when open for use on resident .This failure had the potential for formulas and tubings to be used over shell life . Findings: 1. During a concurrent observation and interview on 5/12/2021, at 12:07 P.M., with the Assistant Director of Nursing (ADON), observed in Station 2 medication storage closet, one bottle of Senna Syrup, natural vegetable laxative had expired 02/2021. ADON confirmed this and stated, Yes, it's expired. During a concurrent observation and interview on 5/13/2021, at 9:59 A.M., with licensed nurse (LN 1), the following expired medications were found inside Station 1 medication cart: -Fexofenadine Hydrochloride expired 11/2020. -Cetirizine HCL 10 milligram (mg) tablets…
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 · D2021-05-14 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the necessary adaptive equipment was provided for one of 24 sampled residents (Resident 17), when spouted cups with handles were not provided on the lunch tray. This failure resulted in Resident 17 not having the appropriate assistive devices to consume drinks with increased risk for aspiration of liquids. Findings: During an observation on 5/11/21, at 12:55 p.m., in the dining room, Resident 17 was eating lunch. The lunch tray had a plate of meat, noodles, vegetables, and a fruit cup. The tray had a glass of tomato juice, two glasses of water, a glass of milk, and a glass of apple juice with a straw. During a concurrent interview and record review of Resident 17's meal tray ticket, on 5/11/21, at 1:05 p.m., with the nursing assistant (CNA 2), the meal tray ticket indicated Resident 17 was to have a two-handled spouted cup for each drink. There were no two handled spouted cups observed on Resident 17's tray. CNA 2 acknowledged Resident 17's lunch tray should have a two-handled spouted cup for each…
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 before2021-05-14 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, and interview, the facility failed to maintain a sanitary environment in the kitchen. This facility failure had the potential for residents meals to be contaminated with dust and debris. Findings: During an observation on 5/12/21, at 12:23 p.m., in the facility kitchen, three fans were observed covered in dust and debris. One fan was in operation and angled toward kitchen staff plating food for residents. During an interview, on 5/12/21, at 12:45 p.m., with dietary manager (DM 1), DM 1 agreed the three kitchen fans needed cleaning and indicated he would inform the maintenance supervisor to clean the kitchen fans.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to COMPASS HEALTH, INC. — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 5.0 | ≈ chain avg |
| Health inspection | 5 of 5 | 5.0 | ≈ chain avg |
| Staffing | 4 of 5 | 3.7 | +0.3 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 6 homes this chain runs (chain average 5.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| HODGE, TIMOTHY | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2024 |
| MOYA, MARIE | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/14/2019 |
| SMITH, DARREN | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | since 01/13/2026 |
| WOOLPERT, PATRICK | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/14/2019 |
| COMPASS HEALTH INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/19/2007 |
| CASTILLO, CARLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/08/2025 |
| DOWNEY, SUSAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2019 |
CMS files one row per role, so the 24 rows in the source record cover these 7 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.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 056189. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-13, 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.