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Creekside Healthcare Center

1900 Church Lane, San Pablo, CA 94806 · For profit - Partnership · 80 certified beds · (510) 235-5514 Medicare & Medicaid certified

Call the home — (510) 235-5514 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2022Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2022
  • a high number of inspection citations overall (21) — 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.

5/5
CMS overall
5 of 5
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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2101 Vale Rd · (510) 233-9300 · Call to confirm hours
Pharmacy
13691 San Pablo Ave · (510) 233-9467 · Call to confirm hours
Grocery
13901 San Pablo Ave · (510) 965-1507 · Call to confirm hours
Park
5 Church Ln · (510) 215-3092 · Typically dawn to dusk
Place of worship
13751 San Pablo Ave

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 3 of 5
Short-stay residentsrehab / post-hospital 3 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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased16.9%10.2%15.4%typical
Long-stay residents who lose too much weight5.3%4.0%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection1.4%1.2%2.0%better
Long-stay residents with depressive symptoms4.1%7.3%6.5%better
Long-stay residents who were physically restrained1.3%0.4%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.3%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened18.6%9.8%16.1%worse
Long-stay residents on antianxiety or hypnotic medication6.0%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers17.1%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control7.7%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 table11.9%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission32.0%23.0%22.6%worse
Short-stay residents with an outpatient ER visit11.6%11.2%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.832.251.67worse
Long-stay outpatient ER visits per 1,000 resident days2.601.571.80worse

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.

48.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.9%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
78.6%U.S. median 56.6%
Met the expected recovery
0.36U.S. median 0.31
Therapy hours / resident / day
0.25hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 78.6% 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 28 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.

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

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.9%CMS range 37.1–58.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 7.7–15.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge78.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge57.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge71.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified64.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 3.5–12.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.301.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.85
RN hours/ resident / day
0.74
LPN hours/ resident / day
2.55
Aide hours/ resident / day
5.13
Total nurse hours/ resident / day
1.65
RN hoursweekends
38.8%
Total nursing turnover
40.7%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 70.3 residents a day — about 88% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 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 4.74 hrs/resident/day on weekends vs 5.29 on weekdays — 10% thinner on weekends. RN hours go from 1.93 to 1.65 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.

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

Inspection trend

3
deficiencies at the latest standard inspection (2025-08-08)
9
at the previous standard inspection (2024-05-24)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · D2026-02-23 · tag F0573 — isolated
    Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of four sampled residents (Resident 1), the facility failed to provide Resident 1's Responsible Party (RP) copies of requested medical records within the required timeframe when she requested Resident 1's medical records by mail on [DATE] and sent the same request with documents via fax on [DATE]. The requested medical records were not released until [DATE] after the RP got a lawyer to make the same request on her behalf.This failure resulted in a delay in obtaining Resident 1's medical records, causing RP undue concern pertaining to obtaining the requested medical records.Findings:During a record review of Resident 1's admission Record (AR), undated, the AR indicated Resident 1 was admitted to the facility on [DATE] and discharged on [DATE], with discharge reason: Expired.During a phone interview on [DATE] at 11:15 a.m. with the RP, RP stated there was no response from the facility regarding Resident 1's medical records request sent in [DATE]. RP stated she sent 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-08 · tag F0644 — pattern
    Coordinate 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of four sampled residents (Resident 3, Resident 18, and Resident 45) Preadmission Screening and Resident Review (PASRR) were screened and referred to the appropriate state mental authority for Level II PASRR evaluation and determination.(PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care). This failure had the potential to prevent residents from receiving appropriate required mental health services. During a review of Resident 3's Minimum Data Set (MDS-an assessment screening tool used to guide care), dated 6/19/25 the MDS indicated Resident 3 was admitted to the facility on [DATE] with diagnosis that included post-traumatic stress disorder (PTSD a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), anxiety disorder (a mental health disorder characterized by…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-08 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure infection control practices were observed by one of one sampled laundry staff (LS) when the LS was not wearing a gown while moving soiled linen from the soiled linen hamper in to the washer.This failure had the potential for cross contamination and spread of infections among 72 residents at the facility.During a concurrent observation and interview on 8/7/25 at 10:09 a.m. with the LS and Certified Nursing Assistant (CNA) 1 in the laundry room, the LS was observed grasping soiled linen from the hamper in to the washer only with gloved hands. The LS stated she had never used a gown or was told to use a gown when putting the dirty linen in to the machine. The LS stated wearing the gown could protect staff and other residents from the spread of infection.During a concurrent observation and interview on 8/7/25 at 10:15 a.m. with the Laundry Staff Supervisor (LSS) in the laundry room, the LS continued to move the soiled linen from the hamper in to the washer with only gloved hands. The LSS stated gown should…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-08 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide routine medications to meet the needs of one of two sampled residents (Resident 62) and ensured controlled medications (those with high potential for abuse and addiction) were accurately reconciled for two of three sampled residents (Resident 3 and 39) when:1.Resident 62's basaglar insulin (medication used to help manage blood sugar levels) and epogen (medication used to treat anemia, a condition where the blood doesn't carry enough oxygen to the rest of the body) were not available for administration. These failures resulted in Resident 62 to not receive medications as ordered by the physician.2.Resident 3 and 39's controlled drug records were documented illegibly. These failures resulted in inaccurate accountability of controlled medications and potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purpose not intended by the prescriber) of controlled medications.1. During a review of Resident 62's Face Sheet, printed on 8/6/25, the Face Sheet…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-05-24 · tag F0925 — failed to control pests — widespread
    Make 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 maintain an effective pest control program for flies and gnats in three of three units designated for resident care. A dead kitten was found outside Resident 24's window for more than 22 hours. The failure to effectively treat flies and gnats and leaving the dead kitten outside Resident 24's room resulted in Resident 24 feeling ugly and grossed out and had the potential to result in infection for all residents residing at the facility. Findings: During an observation on 5/20/24 at 10:05 a.m., three flies were observed in Resident 322's room. During a concurrent observation and interview on 5/20/24 at 10:24 a.m., three flies were observed in Resident 42's room. Resident 42 stated that the facility has numerous flies and that the flies made him feel unsanitary. During a concurrent observation and interview on 5/20/24 at 11:20 a.m., in Resident 34's room, there were five flies in Resident 34's room on the overbed table, the wall, the curtain, and the ceiling. Resident 34 stated that there are flies all over 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-24 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure 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 maintain a medication error rate of less than 5 %. During the medication pass, three medication errors were observed out of 32 opportunities for three of six residents, resulting in an error rate of 9.38%. 1. Amlodipine (medication for management of high blood pressure) for Resident 1 was unavailable and not administered as ordered. This failure had the potential to result in uncontrolled high blood pressure. 2. Semglee pen U-100 insulin (Insulin Glargine, a long acting insulin) subcutaneous injection was administered to Resident 45 without following manufacturer's recommendation. This failure had the potential to affect the insulin dose's effectiveness and the resident's blood sugar. 3. Humulin R Regular U-100 insulin (a short acting insulin) subcutaneous injection was administered to Resident 19 without following the manufacturer's recommendation. This failure had the potential to affect the insulin dose's effectiveness and the resident's blood sugar. Findings: 1. During a review of Resident 1's admission…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-24 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store medications and biologicals (a class of medications which are grown and then purified from large-scale cell cultures of bacteria or yeast, or plant or animal cells) in a safe condition when the temperature in one of two medication refrigerators was out of range in accordance with Federal, State, and CDC storage and handling guidelines. This failure had the potential to compromise the integrity and effectiveness of medications and biologicals and could potentially cause harm to the resident. During a concurrent interview and observation of medication refrigerator 2 (med fridge 2) on 5/21/24 at 11:55 a.m. with RN2, in medication storage room [ROOM NUMBER], the thermometer inside med fridge 2 indicated 32 degrees (°) Fahrenheit (F). Inside med fridge 2, were two E kits (Emergency medication kits) with the same contents in each kit with a yellow sticker indicating Refrigerate. The label on the kit indicated the unopened contents…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-24 · tag F0847 — pattern
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, for three of three sampled residents (Resident 49, Resident 65 and Resident 68) reviewed for arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute [disagreement or claim among parties where one party claims to have been harmed] after receiving evidence and hearing arguments) agreement, the facility failed to ensure the arbitration agreement was explained in a manner they understood. This failure had the potential to result in violation of the residents' right to make informed decisions and choices about important aspects of healthcare and welfare. Findings: 1. During a review of Resident 49's Resident Face Sheet, the Resident Face Sheet indicated Resident 49 was re-admitted to the facility in April 2024, Resident Representative (RR) 1 was listed as Resident 49's Representative. During a review of Resident 49's Minimum Data Set Assessment (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan),…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 observation, interview, and record review, the facility failed to accurately assess one of four sampled residents (Resident 322) for right forearm swelling. This failure resulted in Resident 322 experiencing pain and limited range of motion of the right arm, and placed Resident 322 at risk of untreated edema, further pain skin damage, and fluid overload. Findings: During a review of Resident 322's Face Sheet (a document used to communicate important information about a resident), undated, the record indicated Resident 322 was admitted to the facility in May 2024. During a review of Resident 322s Data Collection (a document used to collect data upon admission for a resident), dated 5/13/24, the record indicated Resident 322 had [right upper extremity] swelling present upon admission to the facility. During a concurrent observation and interview with Resident 322 on 5/20/24 at 10:05 a.m., Resident 322 stated his right arm was swollen and painful to the touch. Resident 322 was laying in bed with the head of the bed elevated, with a pillow under his head. Resident 322's right…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide an environment and a safe transfer to prevent accident for one of eight sampled (Resident 2) when Resident 2 fell from the Hoyer lift during transfer from bed to chair by a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN). This deficient practice resulted in Resident 2 sustaining a superficial scalp laceration and hematoma due to the witnessed fall from the Hoyer lift. Findings: During a review of Resident 2's admission Record, undated, the admission Record indicated medical diagnoses that included Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), dementia (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life), aphasia (a language disorder caused by damage to parts of the brain that control speech and understanding of language), chronic kidney disease, sensorineural hearing loss (happens when there is damage in the inner ear), and high blood pressure. During a review of Resident 2's Minimum…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · Dcited before2024-05-24 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide adequate pharmaceutical services when Resident 1's medication, amlodipine (medication used to treat high blood pressure) was not available and not administered as ordered. This failure had the potential to result in uncontrolled high blood pressure for Resident 1 During a review of Resident 1's admission Record, undated, the admission Record indicated Resident 1 was admitted in December 2019 with diagnoses that included hypertension, chronic kidney disease, and dementia. During a concurrent medication pass observation and interview on 5/22/24 at 9:18 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 checked Resident 1's blood pressure and stated Resident's BP was 125/58. LVN stated order indicated to hold if Systolic BP is less than 100. LVN 2 prepared medications for Resident 1 for the 9 am administration time. LVN 2 unable to find amlodipine, the bubble pack was empty. LVN 2 stated it was supposed to be supplied by pharmacy and doesn't why they do not have it. LVN 2 stated they usually request in…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 68) received quetiapine (an antipsychotic medication, a class of medication that affects brain activities associated with mental processes and behavior) without an appropriate indication for use or appropriate behavior monitoring. This failure resulted in Resident 68's behavior not being appropriately monitored for the use of quetiapine and placed Resident 68 at risk of experiencing untreated psychosocial distress. Findings: During a review of Resident 68's Resident Face Sheet, the record indicated Resident 68 was admitted to the facility in March 2024 with a diagnoses to include unspecified dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior) without behavioral disturbance (a condition where a person behaves in a manner that may put themselves or others at risk), psychotic disturbance (a condition where a person's thinking is disconnected from…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-24 · tag F0836 — isolated
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to follow its policy and procedure to report the fall incident of Resident 2 to the California Department of Public Health (CDPH) and other appropriate agencies, as required by the federal or state regulations. This failure had the potential in delay of investigation and affects the health, safety, or welfare of residents. Findings: During a review of Resident 2's admission Record, undated, the admission Record indicated medical diagnoses that included Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), dementia (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life), aphasia (a language disorder caused by damage to parts of the brain that control speech and understanding of language), chronic kidney disease, sensorineural hearing loss (happens when there is damage in the inner ear), and high blood pressure. During a review of Resident 2's Interdisciplinary Team (IDT) Summary of Investigation, dated 5/1/24, the IDT summary indicated, On…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-11 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 care plan was reviewed and revised by the interdisciplinary team after an identified concern for one of three sample selected residents (Resident 1) when Resident 1 informed the staff of the facility about his sensitivity to the scents. The facility did not make a care plan and follow up with Resident 1's concern. This failure resulted in frustration for Resident 1 and having to inform each of the staff himself about his issue with scents. Findings: A review of Resident 1's Face Sheet indicated Resident 1 was admitted to the facility with multiple diagnoses including acute bronchospasm (happens when the muscles that line your airways in your lungs tighten) and Chronic Obstructive Pulmonary Disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). During an interview on 4/10/24 at 10:25 a.m. with Resident 1, Resident 1 stated that he had high sensitivity to fragrances and scents and when he was admitted to the facility, he told every staff and administrator about…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-05-05 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe medication storage when the eye drops and ear drops were stored next to each other in green and white boxes and there was an expired 1000 ml (milliliter) bag of 10% Dextrose (sugar water solution given intravenously or into the vein) in the medication storage room. These failures had the potential for medication errors to occur (for example, administering ear medication into the eye which could cause blindness) or or the resident to receive expired intravenous (IV) fluids. Findings: 1. During an observation on [DATE] at 11:15 a.m., there were eye drops and ear drops kept next to each other on a shelf. Both were in green and white boxes. During an interview with the Registered Nurse (RN) 2 on [DATE] at 11:15 a.m., RN 2 stated they should not be stored next to each other because it would be easy to grab the wrong one. 2. During an observation of the Medication Storage Room on [DATE] at 11:15 a.m., there was a bag of 10% Dextrose…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-05-05 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, the facility failed to follow a current seasonal menu and meal plan when the facility used the Fall/Winter 2021 menu to prepare the residents' meals. This deficient practice did not ensure seasonal foods which offer variety, palatability, and nutritional value were made available to residents. Findings: During an interview on 5/2/22 at 11:11a.m., the Certified Dietary Manager (DS) provided a copy of the menu titled, Fall/Winter 2021. DS stated the facility currently uses the Fall/Winter 2021 menu to prepare the residents' meal. During an interview on 5/2/22 at 12:42 p.m., the Registered Dietician (RD) stated the spring menu cycle began in April 2022. RD stated the facility had contacted the menu provider in order to initiate the new menu cycle. During an interview on 5/3/22 at 10:06 a.m., the Administrator (Admin) stated the facility had been in contact with the menu provider for updated seasonal menus and continued to wait. During the tray line observation on 5/3/22 at 11:33 a.m., the facility used the Fall/Winter 2021 menu 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-05-05 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to serve palatable food when the facility served chicken rice soup that was too salty. This deficient practice had the potential to cause residents to not enjoy their meal and decline to eat. Findings: Review of the Fall/Winter 2021 menu indicated the lunch menu included, Mediterranean style cod, rice pilaf, carrot, wheat roll, margarine, strawberries with whipped topping, coffee with tea, milk with garnish of choice. During the tray line observation on 5/3/22 at 11:33 a.m., the facility served for lunch- Fish, carrot and rice pillar, gravy, tomato soup, chicken and rice soup, baked chicken, mashed potato, beef patties, broccoli, puree fish, and chicken ravioli as the alternate choice. During a sampled meal tray test on 5/03/22 at 1:21 p.m., accompanied by the Certified Dietary Manager (DS), and test tasted by the Registered Dietician (RD) and the Surveyor, the chicken and rice soup tasted too salty. DS stated the soup was canned soup and the facility will work on it. The facility's policy and procedure, titled Food Service…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-05-05 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, the facility failed to follow proper sanitation and food storage practices as follows: a. Dishwashing racks with brownish discoloration, b. Plate covers had a faded, discolored appearance c. Air vent had a thick layer of black dust. These deficient practices had the potential to result in foodborne illness. Findings: During the initial observation tour of the kitchen on 5/02/22 at 9:47 a.m., accompanied by the Certified Dietary Manager (DS), the dishwashing racks had brownish discoloration, plate covers had a faded discolored appearance, and the air vent had a thick layer of black dust. During an interview on 5/02/22 at 9:47 a.m., DS stated the Maintenance Supervisor (MS) was responsible for the cleaning of the kitchen air vent. DS stated the dishwashing racks and plate covers will be ordered and replaced. During an interview on 5/05/22 at 9:05 a.m., MS stated the air vent in the kitchen was supposed to be cleaned weekly. MS further stated the facility had a contractor that does the cleaning, but unfortunately, was not cleaned…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure one resident (Resident 274) of two sampled residents (Resident 47 and 274) was free from physical abuse when; Resident 47 grabbed Resident 274 on the back of the neck during an altercation in the lobby area. This deficient practice resulted in repeated episodes of resident to resident altercation and had the potential to cause emotional distress, pain, and injury. Findings: During an interview on 5/3/22 at 10:00 a.m., Resident 274 stated Resident 47 bumped into his wheelchair at the lobby area and grabbed him on the back of his neck. Resident 274 stated he was traumatized. During an interview on 5/3/22 at 10:09 a.m., Resident 47 stated Resident 274 was his roommate. Resident 47 stated he grabbed Resident 274 on the back of his neck because Resident 274 had called him the N word and snored. Resident 47 stated he was upset, and when he bumped into Resident 274 in the lobby, he grabbed his neck and staff separated them immediately. Review 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to revised one of two sampled residents (Resident 47) care plans with new interventions to address Resident 47's aggressive arguments and complaint. This deficient practice did not ensure interventions were developed and implemented to avoid repeat altercations. Findings: Review of the nursing progress notes dated 4/19/22, indicated Resident 47 had arguments with Resident 274 in the hallway and tried to gain access to Resident 274. The on duty nurse documented Resident 47 continued to yell at Resident 274 and would not stop which required the on duty nurse to separate the residents. A room change was considered at that time following the altercation. During an interview on 5/4/22 at 12:54 p.m., the Registered Nurse (RN 1) stated she was the on duty charge nurse on 4/19/22 when Resident 47 argued and yelled at Resident 274 in the hallways. RN 1 stated she verbally notified her supervisor. During an interview on 5/4/22 at 9:06 a.m., the Licensed Vocational Nurse (LVN 1) stated Resident 47 had complained about loud noise 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-05 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, for one (Resident 27) of five random sampled resident charts reviewed for their pneumonia vaccination, the facility failed to offer the pneumococcal vaccine recommended by the Advisory Committee on Immunizations Practices (ACIP-group of medical a public health experts) based on the age group and had no medical contraindication against it. This failure increased the risk and potential for Resident 27 to acquire, transmit or experience complications from pneumococcal disease. Findings: During a concurrent interview and medical record review on 05/04/22 at 8:30 A.M., Resident 27's documented date for pneumonia vaccine indicated it was given at the hospital in 2014. The Infection Preventionist (IP) stated she could not find a recent date of when the pneumonia vaccine was given to Resident 27. IP stated the hospital kept track of the pneumonia vaccine record and would request a copy. IP further stated the IP, the Director of Nursing (DON) and nurse supervisor are responsible 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MARINER HEALTH CARE — 17 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 53.6+1.4 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 5 of 54.2+0.8 vs chain
Quality measures 3 of 54.4-1.4 vs chain
The other 16 homes this chain runs (chain average 3.6★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
GC HOLDING COMPANY 2 LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST99%since 06/30/2015
GRANCARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/30/2015
MARINER HEALTH CARE, INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/30/2015
MHC HOLDING COMPANYOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/30/2015
MHC WEST HOLDING COMPANYOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/30/2015
NATIONAL SENIOR CARE, INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/30/2015
GRUNSTEIN, EMILYIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/06/2019
ROTICH, JANETIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/24/2000
SARCAUGA, DENNISIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/06/2025
DHUGGA, GURPREETIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2022
KAUR, NAVJOTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/09/2026
CREEKSIDE HOLDING COMPANY GP LLCOrganizationGENERAL PARTNERSHIP INTERESTsince 06/30/2015

CMS files one row per role, so the 19 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

$11.8M
Net patient revenuemost recent cost report
-9.7%
Operating marginrevenue minus expenses
$1.2M
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 82%Medicare 13%Other / private 6%

About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$487per resident / day
operating cost
$14,811per month
≈ monthly operating cost
$444per day
avg. revenue, all payers

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

What families pay in CA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055099. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-08, 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.

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