Brookside Skilled Nursing Hospital
2620 Flores Street, San Mateo, CA 94403 · Non profit - Corporation · 96 certified beds · (650) 349-2161 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- 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 (5/5)
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (22) — 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 | 13.6% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.6% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.6% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.4% | 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 | 1.4% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 25.2% | 9.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 8.4% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.5% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 6.6% | 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 | 7.1% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 85.6% | 93.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 27.2% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 20.7% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.34 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.56 | 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.
69.3% 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 141 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 13.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 75 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 69.3%CMS range 63.3–75.2 | 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 | 9.2%CMS range 6.5–12.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 13.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 14.7% | 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 | 13.3% | 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 | 99.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.4% | 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 | 2.1% | 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 | 6.2%CMS range 3.5–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.85 | 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 96 beds and averages 78.4 residents a day — about 82% occupied, or roughly 18 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.16 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.61 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 3.76 hrs/resident/day on weekends vs 4.33 on weekdays — 13% thinner on weekends. RN hours go from 0.99 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · Ecited before2026-04-16 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure food were stored and prepared in a sanitary manner when these were observed during kitchen tour:1. The walk-in refrigerator had one grape and one nut on the floor.2. There was ice built up in the freezer on the center support.3. Debris were found under the Freezer: one small potato, one packet of mustard, red onion skin, and debris.4. Five items were found opened but not dated in the cabinet: hot green salsa, food coloring, vanilla extract, cinnamon sticks, browning and seasoning sauce.5. One item found opened with no label and no date: chili oil.6. Three fruit flies were found in the kitchen.7. The interior of two ovens were not cleaned.8. One dirty spatula was stored in the clean utensil drawer.9. Six water pitchers were wet and stored in an enclosed cabinet. These failures had the potential for contaminated and/or expired food items to be served to residents.Findings: During a concurrent observation and interview with the Dietary Supervisor (DS) on 4/13/26 at 9:13 AM, these were observed during…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-16 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 there was an effective pest control program when fruit flies were found in the kitchen. Additionally, three broken window screens and one sliding door screen were observed during tour. These damaged screens are potential entry points for flying pests. These failures did not ensure residents' environment was free from pests.Findings: During a concurrent kitchen observation and interview on 4/13/26 at 9:13 AM, three fruit flies were seen in the kitchen. These observations were confirmed with the Dietary supervisor during an interview. During a concurrent observation and interview on 4/14/26 at 8:29 AM, These were found at the courtyard:Sliding door screen had a hole.One window screen had a hole.Two window screens had damaged/bent frames. Leaving a gap for flying pest.These observations were confirmed with the Maintenance Assistance (MAS) during an interview. The MAS said he checks screens daily. The MAS could not explain how he failed to detect the damaged screens.Review of the facility's policy titled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-16 · 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 interview and record review, the facility failed to ensure target behaviors for the use of Zyprexa (an anti-psychotic medication that changes brain chemistry to stabilize mood and reduce hallucinations=seeing or hearing things that are not there) were accurate, specific, and individualized for Resident 2, one of five residents on these types of medication. This failure did not ensure staff were monitoring the right target behaviors and/or formulated appropriate interventions for Resident 2 within her care plans.Findings:Review of Resident 2's medical record titled MH Progress Note (Mental Health), dated 1/17/24, indicated Resident 2 .has been experiencing feelings of depression, .her current condition has left her bedridden, which has led to feelings of hopelessness.She also has a history of bipolar disorder (a mental illness characterized by extreme mood swings: emotional highs and deep depressions). She has had three suicide attempts.She reports having panic attacks.She is currently on.low dose .(Zyprexa) for her mental Health issues. The . (Zyprexa) is now 2.5 mg daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility did not ensure coordination and collaboration with Hospice agency on developing and ongoing communication of plan of care for one of three residents, Resident 11.This failure could delay Hospice service when changes of condition occurs. Findings:During a review of Resident 11's Face Sheet, indicated, admitted on [DATE] with diagnoses including: Hemiplegia and hemiparesis following cerebral Infarction (weakness and paralysis of extremities due to dead brain tissue) Dementia( a decline in mental ability that interferes with daily life activities), Encounter for Palliative Care(a specialized care for people with serious illness focusing on relieving symptom, comfort and support).During an observation on 4/13/26 at 11 AM, resident in bed, have both eyes closed, not responsive to name call.During a review of Resident 11's physician's order, On Hospice - Pathways Home Health and Hospice Services, dated 12/18/25.During a review of Care Plan, started…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-16 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. This failure resulted in a medication administration total error rate of 9% with a total of three errors out of thirty three opportunities for errors.During a concurrent observation and interview on 04/15/2026 at 8:38 AM with Licensed Vocational Nurse 1 (LVN 1) during medication administration preparation for Resident 25, LVN 1 mixed water with the polyethylene glycol 3350 powder (an unflavored powder used to treat occasional constipation) and was unable to state how much water was used to dissolve the polyethylene glycol 3350 powder. Resident 25 was not informed by LVN 1 that polyethylene glycol 3350 solution was being administered until after Resident 25 had already consumed the polyethylene glycol 3350 solution. During an observation on 04/15/2026 at 9:31 AM during medication administration for Resident 22, Registered Nurse 1 (RN 1) administered a total of eight medications to Resident 22: RN 1 administered Metformin 1000 mg tablet to Resident 22, but the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facilty failed to administer the prescribed Morphine Sulfate (a strong pain medication) to one of five sampled residents (Resident 1) as ordered when: Morphine Sulfate was prescribed on 2/13/24, and was given almost 24 hours later on 2/14/24. This failure had the potential to cause Resident 1 to feel discomfort while dying on comfort care. Findings: A review of Resident 1's brief interview for mental status (BIMS- evaluates cognitive impairment and can help dementia diagnosis) score of 7 indicating severe cognitive impairment. She was admitted with diagnoses of: low back pain (primary diagnosis), signs of declining cognitive function and awareness , mixed hyperlipidemia (a condition where multiple types of lipids (fats) in the blood are elevated above normal levels), and dysphagia (difficulty swallowing) among others. During a review of Resident 1's progress notes, dated from 01/01/24 to 02/28/24, it indicated, on 2/13/24 at 3:34 PM the Director of Nursing (DON) recieved the doctor's order for : Morphine Concentrate oral Solution 20mg…
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 · F2024-10-25 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 Certified Dietary Manager (CDM), the position responsible for supervision of daily food service operations, was fully qualified when the facility did not have a full-time kitchen manager. This failure had the potential for inadequate supervision of the dietary department for 73 out of 75 residents who received food from the kitchen. Findings: During a concurrent observation and interview on 10/21/24 at 9:33 a.m., with [NAME] 1 in the kitchen, the facility's kitchen manager was not seen. [NAME] 1 stated, Right now, we don't have a kitchen manager, when asked to bring in the facility's kitchen manager at this time. [NAME] 1 stated, Two days a week, somebody is coming to help . He is coming Tuesdays and Thursdays when asked about their kitchen manager. During an interview on 10/21/24 at 11:26 a.m., with Director of Nursing (DON), DON stated, Not today, when asked if the facility had the kitchen manager that day. DON sated, the kitchen manager comes twice a week, on Tuesdays and Thursdays. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-25 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent (5%). During the medication pass on 10/22/24, four medication errors were observed out of thirty-three opportunities for two out of four residents, resulting in an error rate of 12.12%. This failure had the potential to result in harm in the health and safety of residents. Findings: 1. According to the facility policy, Medication Administration - Eye Drops, Section 7.11, dated 05/2016, to ensure safe and accurate administration of eye drops according to facility, staff should begin by washing their hands thoroughly and putting on gloves, reducing the risk of contamination and protecting patient safety. Using a gloved finger, gently pull down the patient's lower eyelid to create a small pouch, an area ideal for placing the medication with minimal risk of spills or eye irritation. Instruct the patient to look upward, exposing the eye pouch and facilitating precise administration of the drops. Position the eye drop bottle close to the eye, being careful not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-25 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage in the kitchen when: 1. There were 4 rotten tomatoes with the delivery date of 10/9/24 in the walk-in refrigerator. 2. There were 4 apple pies on a tray with no label/expiration dates, covered with one aluminum tray with black colored old grime in the refrigerator #2. 3. There was a bag of chicken wings with no label/expiration date in the freezer #2. These failures had the potential to put residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview on 10/21/24 at 9:57 a.m., with [NAME] 1 in the kitchen, there were 4 rotten tomatoes with the date of 10/9/24 in the walk-in refrigerator. [NAME] 1 stated, It's not good. We have to throw it away when asked if the 4 rotten tomatoes looked ok. [NAME] 1 stated, 10/9/24 was the delivery date and the tomatoes were good for 7 days from the delivery date when asked. [NAME] 1 acknowledged, the 4 rotten tomatoes were over 7 days, so they were expired already, then she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, facility did not ensure Hospice services and interventions were addressed for one (Resident 4) of 18 sampled residents, when the care plan did not include specific coordination and communication plan of care between the facility and the hospice agency. This failure had the potential to result in not providing the needed plan of care and specific services to Resident 4. Findings: During a review of Resident 4 admission Record dated 10/21/2024, the admission Record indicated, Resident 4 was admitted to Hospice A on 4/5/2024 and to Hospice B started on 10/4/2023 with the diagnosis of Cerebrovascular Dementia (a progressive state of decline in mental abilities). During an interview on 10/23/24 at 11:05 a.m., with Director of Nursing (DON), the DON stated, I have to look, didn't see it here. Unfortunately, we don't have the coordinated care plan, but we have care conference every quarter we don't have a contract agreement but we one-time letter agreement. During an interview on 10/23/24 at 02:51p.m., with Director of Social Services (DSS), DSS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · D2024-10-25 · 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 observations, interviews, and record reviews, it was determined that two separate vials of incorrectly labeled eye drop medications lacked proper labels for prescription medications for a resident. This is an issue because the absence of labels can lead to confusion in medication administration, increasing the risk of administering the wrong medication or dosage, which could adversely affect the resident's health and safety. Findings: A review of the facility's Section 7.1 Medication Administration Policy indicates that the facility had protocols in place for all medications to have proper labeling and organization. On 10/22/24 at 09:55 AM the inspection of the medication storage revealed two vials of prescription eye drop medications stored together, neither of which had a prescription label. Consequently, it was unclear to which resident the medications were prescribed. In an interview conducted on 10/22/24 at 12:05 PM, the licensed staff member stated, Those meds should have both the name of the resident and the date they were opened. When questioned about the mislabeled…
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 · D2024-09-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 report an allegation of resident to resident abuse and injury of unknown source within the required 2-hour timeframe to the State Survey Agency (SSA- where state law provides for jurisdiction in long-term care facilities) for three (3) of six sampled residents (Resident 1, Resident 2, and Resident 3). The deficient practice had the potential for delayed provision of care and the potential to compromise the protection of the residents in the facility which could affect the resident's wellbeing. Findings: 1. During a review of Resident 1's Resident Face Sheet (resident profile) indicated, was admitted on [DATE] with diagnoses including stroke, atherosclerosis of aorta (a condition that occurs when plaque builds up in the aorta, the main artery that carries oxygen-rich blood from the heart to the body), high blood pressure, high blood sugar, and chronic low back pain. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-01-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner. 1. Opened food items were not properly dated and stored. 2. Fresh produce in the refrigerator had mold-like substance. 3. Thawed, uncooked poultry in the refrigerator was not properly dated and stored. 4. [NAME] (C) 2 did not follow proper sanitation and food handling practices during tray line service and did not perform hand hygiene after removing gloves. 5. Temperature and storage conditions for emergency food kits were not monitored. 6. Food Service Manager (FSM) wore jewelry in the kitchen. 7. Kitchen tools and patient food trays were not maintained in good condition. 8. Coffee mugs belonging to facility staff were stored in the kitchen cabinets. These deficient practices had the potential to put residents at risk for foodborne illnesses. Findings: 1. During an initial kitchen tour observation and concurrent interview on 1/11/22, at 9:14 AM, with [NAME] (C) 1 present, the following food items were found inside the kitchen cabinet next 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 · Fcited before2022-01-14 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 an effective pest control program. 1. [NAME] 1 did not report sighting of a roach in the kitchen counter. 2. Recommendations made by the pest control company were not followed. These failure had the potential to not eradicate and contain common household pests in the facility to prevent contamination, transmission or spread of disease to patients. Findings: 1. During an initial kitchen tour on 1/11/22 at 9:24 AM, a small insect crawled on the counter where the blender, toaster, and chopping boards were located. [NAME] (C) 1 noted the observation and confirmed that the insect was a roach. C1 got a paper towel and squashed the insect with her hand. During an interview on 1/12/22 at 10:22 AM, with the Maintenance Manager (MM), MM stated, he was aware of pest sightings in the facility from monthly reports issued by the pest control company including from verbal reports made by facility staff. MM stated, the facility did not have a pest sighting log. During an interview on 1/12/22 at 3:14 PM, with the Food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-01-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. One staff did not perform hand hygiene in between resident care activities. 2. One staff was not wearing personal protective equipment (PPE- protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) properly. 3. One of 16 sampled residents (Resident 16) was using a nasal cannula (NC - a flexible tubing that sits inside the nostrils and delivers oxygen) that was not changed weekly. 4. One of 16 sampled residents (Resident 32) was using an unlabeled NC. These failures had the potential for cross-contamination and spread of infectious diseases that could jeopardize the health of the residents, staff, and visitors. Findings: 1. During an observation on 1/11/22 at 10:20 AM, Certified Nursing Assistant (CNA) 2 donned (put on) gloves and assisted Resident 24 to bed. 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 · Dcited before2022-01-14 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a care plan with appropriate nursing interventions for one of four sampled residents (Resident 28) when: There was no care plan for Resident 28's oxygen therapy. This deficient practice had the potential to prevent Resident 28 from receiving appropriate, and individualized care and services consistent with her needs, based upon assessment and physician order. Findings: During a review of the admission record for Resident 28, the admission record indicated, Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included a recent history of pneumonia, pericardial effusion (buildup of too much fluid in the double layered, saclike structure around the heart), diabetes, chronic kidney disease on dialysis (dialysis is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), and hypertension (high blood pressure). During a review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-14 · 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 provide services according to professional standards of quality for one of four sampled residents when: The oxygen order for Resident 28 was not specified whether continuous or as needed basis. This failure had the potential to not deliver oxygen correctly and ensure safe and effective oxygen therapy, which can result to negative consequences to the resident. Findings: During a review of admission record for Resident 28, the admission record indicated resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included pneumonia (lung infection), pericardial effusion (buildup of too much fluid in the double layered, saclike structure around the heart), diabetes (abnormal blood sugar), chronic kidney disease and on dialysis (dialysis is a procedure to remove waste products and excess fluids from the blood when the kidneys stop working properly), and hypertension. During a review of Resident 28 physician's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 29) had weekly assessments and documentation of the pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) on the left buttock. This failure had the potential to result in delayed healing, and ineffective plan of care and treatment of the resident's pressure ulcer. Findings: During a concurrent observation and interview on 1/13/22, at 10:20 AM, Resident 29 was in his bed awake and alert. Resident 29 stated, he was admitted to the facility for rehabilitation due to a fall incident. When asked about other services received, Resident 29 stated, he was treated for a wound on his buttock and said, it was slowly getting better. During a concurrent observation and interview on 1/13/22 at 3:15 PM, with RN 1, inside Resident 29's room, RN 1 inspected the resident's pressure ulcer on the left buttock. RN 1 stated, the pressure ulcer was unstageable (full thickness skin and tissue loss in which the extent of tissue damage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 165) was provided treatment, supervision and appropriate equipment and supplies to prevent accidents related to oral suctioning (a procedure to clear secretions such as mucus from the mouth). 1. There was no assessment and documentation to identify Resident 165's individual risk of an accident, including the need for supervision prior to performing oral suction on her own. 2. Resident 165's care plans did not incorporate oral suctioning procedures consistent with the resident's needs, goals, and facility standards of practice, policies and procedures. 3. There was no physician's order for Resident 165 to self-administer an oral suctioning procedure. 4. Resident 165's oral suctioning and use of suction equipment and supplies were not monitored and documented in accordance with facility standards of practice, policies, and infection prevention and control. These failures had to potential for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2026-04-16 · tag F0911 — patternEnsure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure resident rooms accommodated no more than four residents in each room when one room (Rooms 101) had six residents in the room.This failure had the potential to negatively impact the safety and well-being of residents.Findings:During an observation on 4/13/26 at 10:30 AM, in room [ROOM NUMBER], the room was divided into two sections. The right section had two beds and the left section had four beds. room [ROOM NUMBER] had a common entrance door and a shared bathroom. There was a total of six residents in room [ROOM NUMBER].During observation on 4/14/26 at 10:00 AM room [ROOM NUMBER] measured 581 square feet.During an interview on 4/16/26 at 3:15 PM the Administrator was made aware of this finding.
- No harm found · Bcited before2024-10-25 · tag F0911 — patternEnsure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
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 resident rooms accommodated no more than four residents in each room when room [ROOM NUMBER] had six residents in the room. This failure had the potential to negatively impact the safety and well-being of residents. Findings: During an observation on 10/21/24 at 9:32 AM, in room [ROOM NUMBER], the room was divided into two sections. The right section had two beds and the left section had four beds. room [ROOM NUMBER] had a common entrance door and a shared bathroom. During an observation on 10/21/24 at 2:21 PM, no residents occupied the room. room [ROOM NUMBER] was used as a Physical Therapy (PT) Room. During an interview on 10/24/24 at 1:29 PM, the Administrator stated, she had written a letter to the Centers for Medicare & Medicaid Services (CMS) requesting a waiver for rooms [ROOM NUMBERS]. For now, room [ROOM NUMBER] was used as PT Room. During a review of the room waiver form completed by the Administrator, the waiver…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2022-01-14 · tag F0911 — patternEnsure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
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 resident rooms accommodated no more than four residents in each room when two rooms (rooms [ROOM NUMBERS]) had six residents in each room. This failure had the potential to negatively impact the safety and well-being of residents. Findings: During a interview on 1/11/22 at 9:30 AM, with the Administrator, Administrator stated, she had written a letter to the Centers for Medicare & Medicaid Services (CMS) requesting a waiver for rooms [ROOM NUMBERS] which had six residents in each room. During a review of the room waiver form completed by the Administrator, the waiver indicated, the following floor measurements: Rooms 101 had 581 total square feet, and room [ROOM NUMBER] had 581 total square feet. During an observation on 1/11/22 at 9 AM in room [ROOM NUMBER], there were no concerns about space and the room. room [ROOM NUMBER] was divided into two sections. The right section had two beds and the left section had four beds. room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ST JOHNS VOLUNTEERS | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 01/01/1967 |
| MOTOVILOFF, IRENE | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2000 |
| DANICH, KATHERINE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/1988 |
| DANICH, MICHAEL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2014 |
| DANICH, SVETOSLAV | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/1988 |
| INPATIENT CONSULTANTS OF CALIFORNIA INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/20/2024 |
| SERENITY 4 MANAGEMENT SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2014 |
| GRIMES, JEREMY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2014 |
| GRIMES, VIVIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2014 |
| RODRIGUEZ, ELSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/08/2021 |
| SILVA, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2018 |
CMS files one row per role, so the 31 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
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 055188. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-16, 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.