Casa Dorinda
300 Hot Springs Road, Santa Barbara, CA 93108 · Non profit - Corporation · 52 certified beds · (805) 969-8051 Medicare only — no Medicaid
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,278 in federal fines (most recent 2025-11-18)
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.5% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.7% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.6% | 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 | 5.5% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 6.5% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 30.9% | 13.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 90.3% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.3% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 17.9% | 10.2% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.2% | 12.0% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.5% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 54.1% | 93.2% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 16.6% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 5.4% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.74 | 2.25 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.79 | 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.
59.0% 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 53 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.1% 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 26 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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 | 59.0%CMS range 51.6–70.2 | 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 | 11.6%CMS range 6.9–16.9 | 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 | 46.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 46.1% | 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 | 42.3% | 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 | 97.4% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 4.0–14.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 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 52 beds and averages 35.9 residents a day — about 69% occupied, or roughly 16 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.15 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.86 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 0.00 is below 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 1.83 hrs/resident/day on weekends vs 2.28 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.90 to 0.77 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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 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.
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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · G2025-11-18 · 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 interview and record review, the facility failed to follow their policy and procedure and implement interventions of a fall care plan to ensure a bed alarm was turned on for one of three sampled residents (Resident 1) while Resident 1 was in bed.This facility failure resulted in Resident 1 getting out of bed, falling to the floor and sustaining an acute displaced right hip fracture (broken hip bone that moved so much a gap formed around the fracture).During a review of Resident 1's Face sheet, [undated], the Face sheet indicated, Resident 1 was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease (brain disorder that causes memory loss, confusion, and other cognitive decline), unspecified dementia (loss of brain function), major depressive disorder (low mood, loss of interest or pleasure), recurrent mild muscle weakness, abnormalities of gait and mobility, essential hypertension (high blood pressure without a known cause), primary open-angle glaucoma (eye disease leading…
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 before2026-03-06 · 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 Policy and Procedure (P/P) the facility failed to ensure food safety requirements was followed and implemented whenFailed to discard leftover in the itchen's walk-in-refrigerator.Take temperature of cold foods for lunch meal service to maintain potentially hazardous food and Time/ Temperature Control for Safety PHF/TCS foods at safe temperatures.Ensure kitchen staff during food preparation for meals served to residents wear appropriate beard restraints. Ensure safe food storage when documenting temperatures on the temperature monitoring log exceed 41 degrees Fahrenheit (F) and went unnoticed due to incorrect guidelines listed on the log.1.During a concurrent observation and interview on 3/3/26 at 11:00 a.m. with Nutrition Service Manager (NSM), in the Skilled Nursing Facility (SNF) kitchen's walk-in-refrigerator, observed cooked white rice in a transparent container covered with a plastic wrap with a preparation date of 3/2/26 and cooked pasta in a transparent container, covered and labeled with a preparation date of 2/24/26. NSM stated 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 before2026-03-06 · 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 interview and record review, the facility failed to provide care and all services are provided according to accepted standards of clinical practice for 5 of 12 sampled resident ( (Resident 40, 47 4, 1, and 34) when: Resident 40's nebulizer equipment (tubing and nasal canula) was not stored per facility policy.Resident 47 on oxygen had no signage posted indicating no smoking/oxygen in use.Ensure staff consistently used the unique identifiers to verify resident identity prior to medication administration These facility failures creates a potential for compromised resident outcomes and safety During an observation on 3/4/26 at 7:20 a.m., Licensed Nurse 3 (LN) 3, LN 3 was observed preparing medications for Resident 4. LN 3 entered the resident's room and administered five oral medications to the resident sitting in the chair. At no time did LN 3 ask the Resident to state their name and date of birth before administration. During an interview on 3/4/26 at 7:25 a.m., LN 3 verbalized they identified 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 before2026-03-06 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility Policy and Procedure (P/P), the facility failed to ensure the medical supply rotation policy was implemented when expired medications were found in the medication carts and medication roomsThis facility failure has the potential for medciation error. During an observation of medication room [ROOM NUMBER] on 3/4/26 at 10:10 a.m. located on the first floor behind nursing station, 1 container, Oxivir Tb Wipes, (ready-to-use, hospital-grade disinfectant) with expiration date of 12/28/2023 and 1 bottle of Biotene dry mouth oral rinse, with expiration date of 2/24/2026 was noted.During an interview on 3/4/26 at 10:20 a.m. with licensed nurse (LN1). LN 1 confirmed items were expired and indicated, they should have been removed from stock and disposed.During an observation of medication number 2 3/4/26 at 10:40 a.m. located on the second floor at nursing station, 10 Suppositories of Bisacodyl 10 mg (stimulant laxatives) with expiration date of 2/28/26 was noted.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 · Dcited before2026-03-06 · tag F0801 — isolatedEmploy 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure there is sufficient and qualified staff with the appropriate competencies and skills sets to carry out food and nutrition services when:1. The Nutritional Services Manager (NSM) was competent on the facility's refrigerated food storage guidelines for food safety.2. The NSM responsible for day-to-day food service for the residents at the Medical Center Skilled Nursing Facility (SNF) was qualified in accordance with federal and state regulations (Health and Safety Code (H&SC)1265.4(b) and Title 22 72035), as required per federal regulation.3. The Registered Dietitian (RD) provided frequently scheduled consultation to the NSM to include overseeing food safety and sanitation. Cross Refer F812This failure had the potential for food and nutrition services staff to be inadequately trained and supervised to carry out food and nutrition services.1. During a concurrent observation and interview on 03/03/26 at 10:47 a.m. with NSM inside 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 before2026-03-06 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure 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, interview, and record review the facility failed to ensure food were prepared by methods that conserve nutritive value, flavor, and appearance for five of twelve sampled residents (Resident 1,16, 23,25, and 34) when meals were not consistently served at an appetizing, palatable and preferable temperature as determined by the residents.This failure had the potential to cause weightloss.During a concurrent observation and interview on 3/3/26 at 12:20 p.m., with Nutrition Services Manager (NSM). NSM was observed using a calibrated thermometer to check the internal temperature of waffle fries from a test tray after the last lunch meal tray was served to residents and was noted to be 115 degrees Fahrenheit (F). NSM stated, the waffle fries were not at an acceptable temperature for service and acknowledged, facility has received complaints from residents regarding meals being served cold.During a concurrent observation, interview, and record review on 3/3/26 at 12:49 p.m. in the dining room during lunch. Resident 25 stated, The food has no flavor, and I cannot taste…
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 before2026-03-06 · tag F0851 — isolatedElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to run reports 1700D (employee report), 1702D (individual daily staffing report) and 1702S (staffing summary report) to ensure payroll-based journal (PBJ) data (a system for facilities to submit staffing information on a regular and frequent basis, ensuring accuracy) was received by the Center for Medicare and Medicaid (CMS).This failure resulted in CMS not receiving registered nurse (RN) hours and licensed nursing coverage data for the month of September 2025.Findings:During a review of PBJ Staffing Data Report [NAME] (Certification and Survey Provider Enhanced Reports) Report 1705D, Quarter 4 2025 (September 1- September 30) run on 2/26/26 indicated, One Star Staffing Rating, No RN hours and failed to have Licensed Nursing Coverage 24 hours/day.During an interview on 3/3/26 at 11:08 a.m. with the Director of Nursing (DON), Administrator (ADM) and Assistant Director of Nursing. DON stated, she forgot to send the PBJ Report for September. During a review of the facilities Policy and Procedure (P&P) titled, The DON checks 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 before2026-03-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure infection control practices were implemented when: Enhanced barrier precautions (EBP - Infection control measures the involves wearing personal protective equipment [PPE - protective gear such as gloves, gowns, masks, and eye protection] for specific high-contact tasks such as bathing, transfers, and wound care for at-risk residents to stop germ spread) were not implemented for three of three residents (Resident 3, Resident 4, Resident 40) with indwelling medical devices (instruments placed inside the body to assist with diagnostic, monitoring, or therapeutic functions) A nebulizer mask (a medical device worn over the nose and mouth to deliver liquid medication directly into the airways as a fine mist) used for breathing treatments for Resident 40 was not stored in a manner to maintain hygiene and prevent contaminationSoiled linen bags were found on the floor on two of two soiled linen rooms (SLR). These facility failures had the potential to result in cross-contamination (the transfer of harmful…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-12-05 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to run reports 1700D (employee report), 1702D (individual daily staffing report) and 1702S (staffing summary report) to ensure payroll-based journal (PBJ) data (a system for facilities to submit staffing information on a regular and frequent basis, ensuring accuracy) was received by the Center for Medicare and Medicaid (CMS). This failure resulted in CMS not receiving registered nurse (RN) hours and licensed nursing coverage data for the month of June 2024. Findings: During a review of PBJ Staffing Data Report CASPER (Certification And Survey Provider Enhanced Reports) Report 1705D, Quarter 3 2024 (April 1 - June 30) run 11/25/2024 indicated, One Star Staffing Rating, No RN hours, and failure to have licensed nursing coverage 24 hours/day. During an interview on 12/4/24 at 10:30 a.m. with the Director of Nursing (DON), DON verbalized they are responsible for sending staffing information to CMS, also verbalizing they were not aware of the reports to run to ensure CMS received data sent. During a review of the facility's policy…
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 before2024-12-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow food safety requirements when: 1. Three (3) containers of prepared food were mislabeled as to date prepared of expiry date and is ante-dated (written date is one day after date of inspection) 2. One (1) of three (3) red buckets tested was below the recommended concentration of sanitizing solution. These failures has the potential for food borne illnesses affecting residents when safe refrigerated food are mislabelled, food has no use-by date, and sanitizing solutions are not safe when preparing foods. Findings: 1. During an observation on 12/02/24 at 11:36 a.m. at the kitchen freezer section, three stainless steel containers were identified. Two (2) containers with precut vegetables, and one (1) container with potatoes with spices, covered in clean [NAME] wrap and is labelled as 12/3/24. There is no evidence to indicate a date prepared or use by date. During an interview on 12/3/24 at 11:36 a.m. with Dietary Aide (DA1), DA…
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 before2024-12-05 · 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 the specific inappropriate behavior was documented for one of four sampled residents, (Resident 9) as stated in the careplan. This failure had the potential to inadequately identify what behavior needed to be monitored /planning of intervention to address the resident's inappropriate behavior. Findings: During a review of Resident 9's, admission Record (AR), dated 07/20/21, the AR indicated, Resident 9 had diagnoses including, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out daily activities) with late onset and major depressive disorder. During a review of Resident 9's, Care Plan, dated 10/01/24, the care plan indicated, Monitor and document episodes of inappropriate behavior directly/indirectly towards staff members. Special Instructions: Please be specific and document occurrence or quote in progress notes as well. Three Times A Day 02:00 PM, 10:00 PM, 06:00 AM. During a review Resident 9's, Medication Administration Record (MAR), dated…
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 20 citations
- Potential for harm · D2024-12-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 a care plan for inappropriate behavior was updated to reflect episodes of inappropriate behaviors in one of four sampled residents ( Resident 9) per facility's policy and procedure. This failure had the potential for the Resident 9's inappropriate behaviors to have no effective interventions in place which can affect the resident's daily interactions with others and vice versa affecting the quality of life in the facility. Findings: During a review of Resident 9's, admission Record (AR), dated 07/20/21, the AR indicated, Resident 9 had diagnoses including, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out daily activities) with late onset and major depressive disorder. During a review of Resident 9's, Medication Administration Record (MAR), dated 01/01/24 - 12/04/24, the MAR indicated inappropriate behavior episodes occurred on the following dates: one episode 03/14/24, one episode 03/17/24, one episode 06/21/24, four episodes 06/23/24, one…
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 before2024-12-05 · 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 interview and record review, the facility failed to ensure a doctor's recommendation for a psychiatric consultation was followed up for implementation in one of four sampled residents (Resident # 9). This failure had the potential and risk for the resident's psychosocial health care needs to be unattended which can result in the deterioration of the physical, mental, and psychosocial well-being. Findings: Review of [NAME] and [NAME], seventh Edition, Mosby's Fundamentals of Nursing, page 336 in the section titled, Physician's Orders indicates, Nurses follow physician orders unless they believe the orders are in error or harm clients. Therefore, you need to assess all orders, and if you find one to be erroneous or harmful, clarification from the physician is necessary. During a review of Resident 9's, admission Record (AR), dated 07/20/21, the AR indicated, diagnoses including, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out…
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 · D2024-12-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure one of four sampled residents (Resident 15) development of a foot drop was monitored and assessed for appropriate intervention to prevent further decline in range of motion. This failure resulted in reduced mobility of the foot with potential for contractures ( hardening and stiffening of muscle /bones). Findings: During an observation on 12/3/24, at 2:26 p.m., in room [ROOM NUMBER], Resident 15 was observed on bed, in a supine position (facing upwards) with feet on a pillow. The toes of both feet were noted to be flexed or extending, pointing towards the foot of the bed (outward) instead of upward (towards the ceiling). During a review of Resident 15's Physical Therapy Evaluation & Plan & Treatment, dated 2/11/22, under Musculoskeletal System Assessment, the AROM (Active Range of Motion) - (R) Ankle Dorsiflexion (upward or backward bending of a body part, often referring to a hand or foot) = WNL (Within Normal Limits); Plantar…
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 before2024-12-05 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to ensure the change of shift narcotics reconciliation count was properly counted and signed by two licensed nurses to ensure accuracy of the narcotic/controlled medications. This failure had the potential to result in an inaccurate count and drug diversion (the illegal distribution or abuse of controlled prescription drugs) of controlled medications. Findings: During a medication pass observation, on 12/3/24, at 7:53 a.m., in the East Wing, first floor of the facility, the narcotic count book/log (a book/log recording the systemic monitoring, counting, and documentation of controlled medications/substances every start and end of each shift) for the month of November, was observed to be missing several signatures from both the incoming and outgoing licensed nurses. During record review, the following were noted. On November 21, 2024, the incoming 3-11 shift nurse failed to sign at the start and at the end of the shift. On November 21, 2024, the incoming 11-7 shift nurse failed to sign at the start of the shift…
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 before2024-12-05 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure biologicals were properly stored and labeled and the medications of discharged residents were properly stored, discarded , labeled per policy and procedure . This failure had the potential for biologicals, medications, medication items to be diverted. Findings: During a concurrent medication pass observation and interview, on 12/3/24, at 9:50 a.m., in the East Wing, first floor of the facility, with Registered nurse (RN 2), the following were noted in the 1 East medication cart (EMC). Five plastic containers of Polyethylene Glycol 3350 Powder for Solution (a laxative used to prevent constipation) had the respective room numbers written/labeled on the caps but were missing the open dates. One of the plastic bottles of Polyethylene Glycol 3350 Powder for Solution belonging to a discharged resident . RN 2 inspected the 5 plastic bottles of Polyethylene Glycol 3350 Powder for Solution and stated, The open dates were not labeled, and the bottle of the discharged resident should have been removed from 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 before2024-12-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper handwashing was observed in between vital signs taking and medication pass by one of one nurse (RN 2). This failure had the potential to result in cross contamination and spread of infections to residents , compromising their wellbeing. Findings: During an observation on 12/3/24, at 9:18 a.m., with RN 2, in Unit 1 East, RN 2 was observed using a hand sanitizer on the wall, sanitized his hands and donned surgical gloves, before knocking and entering room [ROOM NUMBER]A with the vital sign machine on wheels. RN 2 failed to sanitize the vital signs machine which was observed previously used on another resident. RN 2 then proceeded to take the resident's vital signs. Subsequently, RN 2 completed the task of obtaining the residents vital signs and proceeded to wheel the vital signs machine out of the room. RN 2 once again, failed to sanitize the vital signs machine after use. RN 2 doffed and disposed of the surgical gloves,…
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 before2024-11-05 · 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
F656 Develop/Implement Comprehensive Care Plan §483.21(b) Comprehensive Care Plans §483.21(b)(1) Based on interview and record review, the facility failed to ensure Resident 1 ' s burn wound care plan included wound measurements and documentation requirements to monitor wound progression towards healing. This failure resulted in resident ' s burn wounds not being measured and documentation performed as required. Finding: During a concurrent review of Resident 1 ' s medical record and interview with the Director of Nursing (DON) on 10/15/24 at 2:00 p.m., the DON reported that on 10/5/24 a License Vocational Nurse (LVN) poured coffee into Resident 1 ' s mug. Resident 1 started sipping the coffee and then accidentally dropped the mug on his lap. Resident 1 sustained a third degree burn on both thighs. The DON reported weekly measurements and documentation of the wounds were performed. The burn wounds were only measured and documented on 10/6/24. The DON confirmed the record does not contain any other measurements and documentation of the resident ' s burn wounds. During a concurrent…
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 before2024-11-05 · 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
F658 Services Provided Meet Professional Standards §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. Based on interview and record review, the facility failed to implement standards of practice when Resident 1 ' s burn wounds were not assessed and documented according to standards of practice and its policy. This failure resulted in resident ' s burn wounds only being assessed and documented only one time. Findings: According to the national institute of health NIH (2023) at https://www.nih.gov. The frequency of burn wound assessments depends on the stage of healing and the patient's needs. Initial assessment: Patients with burns should be seen the day after the injury to assess pain, adjust medication, and check dressing changes. Subsequent assessments: Patients are typically seen weekly until the wound heals. However, if there are concerns about pain control or wound care, the patient may need to be seen daily. A review of the facility policy and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-04-12 · 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 ensure sanitary conditions were maintained in the food and nutrition services when: 1. The high temperature dish machine was not reaching proper wash, rinse and final rinse temperatures in order to effectively sanitize in accordance with the manufacturer's guidelines. 2. The three compartment sink used to wash pots and pans was not implemented in an effective manner to properly wash and sanitize the foodservice equipment. 3. The tube to dispense sanitizer was located in the hand washing sink. These failures had the potential to result in cross contamination and food borne illness in a highly susceptible resident population in which the majority of residents were on oral diets. Cross Reference F801 Findings: 1. During a concurrent observation and interview on 3/14/24 at 11:16 a.m. with dish washer (DW) 1 in the main kitchen, DW 1 was observed running breakfast dishes through the high temperature dish machine. DW 1 observed the wash temperature gauge affixed externally to the dish machine and DW 1 stated 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 · Ecited before2024-04-12 · tag F0801 — patternEmploy 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 director of dining services (DDS/CDM; certified dietary manager) received sufficient frequently scheduled consultations from the facility's Registered Dietitian (RD) to include oversight over sanitation of the main kitchen when: 1. RD had not reviewed the monitoring logs for the main kitchen's high temperature dish machine that resulted in not identifying and addressing sanitation concerns, in a timely manner, related to meal service for the health and safety of residents residing in the skilled nursing facility. 2. RD had not reviewed the monitoring log for the main kitchen's three (3) compartment sink to ensure accurate and complete guidance was available on the log, and followed, related to washing and sanitizing food service equipment in the 3-compartment sink in accordance with the facility's policy and procedures. These deficient practices had the potential to cause foodborne illness to the highly susceptible residents currently residing in the skilled nursing facility (SNF) who received…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-12 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the correct portion size for the regular diet orders, with regular portion sizes (i.e.; meaning not a small portion or large portion) was served following the planned menu. This facility failure had the potential to not meet the resident's nutritional needs for 20 residents who were prescribed a regular diet, with regular portions, per the facility's Resident Diet Information, dated 3/14/24, provided by the Registered Dietitian (RD). (Resident's 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20). Findings: During a concurrent observation and interview on 3/14/24 at 12:01 p.m. with RD in the trayline kitchen (trayline kitchen was the name used by the facility referring to the kitchen that plated food for residents who used meal trays), a Server (1) was observed using a 4 (four) ounce (oz.) serving spoon to plate the main entree of Shrimp and Sausage Jambalaya for the regular diet with regular portion sizes. RD observed the 4 oz. serving spoon placed in the pan of shrimp and sausage…
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 · E2022-10-20 · tag F0802 — failed to prepare enough nourishing food — patternProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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 employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services when: 1. The dishwasher was unable to accurately record dish machine wash water and sanitizing (final rinse) temperatures. The dishwasher was not competent to know when to report a problem to ensure properly washed and sanitized dishes were used for residents. 2. A pot washer was not competent on the correct concentration of sanitizer for the 3-compartment sink to ensure the pots and pans were effectively sanitized. 3. A cook was not competent on thermometer calibration to ensure temperatures obtained were accurate to promote food safety for the residents. These failures placed residents at risk of cross contamination and acquiring foodborne illness. 1. During a concurrent observation and interview on 10/17/22, at 10:00 a.m., with Dish Washer (DW 4), in the main kitchen, DW 4 was observed running dishes through the dish machine. In the presence of the Sous Chef (SC), who…
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 · D2022-10-20 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure an interdisciplinary team (IDT- team members from different discipline with common purpose, to set goals, share responsibilities and make decisions together) meeting was conducted for the self-administration of medication for one of 12 sampled residents (Resident 8). This failure had the potential for Resident 8 to unsafely self-administered a medication, without IDT's approval for self-administration. Findings: During a medication pass observation on 10/18/22, at 8:43 a.m., and a concurrent interview with the Licensed Nurse (LN 2), the surveyor observed a bottle of eye drop, labelled, Soothe-XP - emollient lubricant (medication to moisten the eyes), 15ml, on Resident 8's bedside table. During an interview with LN 2, LN 2 verbalized, he did not know the bottle was there, and had asked Resident 8, Resident 8 informed LN 2, Resident 8 self-administered the medication for dry eyes. LN 2 further verbalized, he had checked the Resident's 8 electronic record (patient's medical information in the computer…
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 · D2022-10-20 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to update the medical records with current wishes for life sustaining treatment (POLST-Physician Order for Life Sustaining Treatment) for one of three sampled residents (Resident 8). This failure had the potential to prevent facility staff and emergency personnel from providing life sustaining treatment to Resident 8 in case of emergency. Findings: During a review of Patient 8's medical record, the POLST (POLST-Physician Order for Life Sustaining Treatment), dated [DATE] indicated, Attempt Resuscitation/CPR (life sustaining treatments in an emergency). The Face Sheet and Physician Order Sheet effective through [DATE] indicated, DNR (DNR-Do Not Resuscitate). During a concurrent interview and record review on [DATE] at 11:50 a.m., Patient 8 reviewed the POLST dated [DATE] and confirmed the signature, date, and Attempt Resuscitation/CPR on the POLST are correct. Resident 8 stated, Yes, in an emergency I want CPR. During a concurrent record review and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure an accurate system for monitoring parameters of nutritional status for one of 2 sampled residents (Resident 16), when: 1. An inaccurate nursing weekly assessment failed to identify a significant weight loss which resulted in a missed referral to the Registered Dietitian (RD). 2. An inaccurate weight goal was documented on the interdisciplinary team (IDT) nutrition care plan that had not been assessed by the RD or involved the decision making of the participant or responsible party (RP). 3. The facility lacked monitoring of a nutrition intervention, such as a high protein shake, when delivered with the meal trays. 4. The IDT nutrition care plan was not updated and revised to reflect changes the RD made to the intervention for weekly weights. As a result, there was potential for the resident's nutritional needs to go unmet. Findings: 1. During a concurrent interview and record review on 10/19/22 at 01:50 p.m., with RD, Resident 16's admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-20 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record, review, the facility failed to follow it's policy and procedures (P&P) (set of rules for employees to follow in an organization) for disposition (process for destroying unused medications) of expired and controlled medications (medications that are potential for abuse), and to reconcile (record keeping) accounting for controlled medications brought from home to the facility by family members for one unsampled resident (Resident 229) when the following was observed on [DATE], during a facility tour: 1. Eight packets of 4 vials each, 0.9% sodium chloride inhalation (nebulazer solution), expiration date 1/17, located at second floor Medication Room. 2. A small biohazard sharps container with narcotic medication as reported by the licensed staffs, located at first floor west station medication cart narcotic drawer. 3. A bottle of Hydrocodone (opiod to treat pain) with 12 tablets and the narcotic count sheet wrapped around the bottle located at first floor west station…
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 · D2022-10-20 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 record review and interview, the facility failed to ensure one of 12 sampled residents (Resident 23) had been assessed for the use of antipsychotic (medicine for mental disorders) while having a diagnosis of dementia (a condition of the brain affecting ability to remember, think or make decisions with doing everyday activities), as outlined in the manufacturer's black box warning. This failure resulted in Resident 23, taking this medication and placed Resident 23, at increased risk of death as outlined by the black box warning and making this as inappropriate drug for Resident 23. Findings: During a review of an untitled document, dated, 10/20/22, the untitled document, indicated, the interdisciplinary team (IDT) (team members from different discipline with common purpose, to set goals, share responsibilities and make decisions together), reviewed Resident 23's plan of care. The untitled document further indicated, Resident 23 had been on Seroquel (type of medicine for mental disorder) while having a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-20 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure 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, interview and record review the facility failed to ensure a cook followed the puree recipe for a puree egg omelet as a method to ensure nutritive value. As a result, the resident was provided a puree egg omelet with less nutritive value than planned. Findings: During a concurrent observation and interview on 10/18/22, at 11:21 a.m., with [NAME] (1), in the kitchen, [NAME] 1 was observed to prepare pureed egg omelet. [NAME] 1 stated, she had one pureed egg omelet to make as a food preference for lunch that day for a resident. [NAME] 1 stated she placed three cooked eggs into the food processor. [NAME] 1 was observed to add one cup of milk and one cup of water and thickener to the food processor. [NAME] 1 was asked how much thickener she used, and [NAME] 1 stated, We don't really measure the thickener. [NAME] 1 stated she goes by overall puree texture consistency versus paying attention to how much thickener was used. [NAME] 1 was shown how much thickener was observed in the glass measuring cup that was added to the food processor and [NAME] 1 verified the amount…
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 · D2022-10-20 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the Registered Dietitian provided care within the scope of practice guidelines of the California Business and Professions Code 2586 (a)(1) when the facility approved order writing privileges to the RD related to writing orders for nutritional supplements and therapeutic diets. As a result, the RD was performing services outside of RD scope of practice per State law. Findings: During a concurrent interview and record review on 10/19/22 at 01:40 p.m., with Registered Dietitian (RD), Resident 16's admission Nutrition Assessment (ANA), dated 8/23/21 was reviewed. The ANA indicated Resident 16 had a significant unplanned weight loss since admission. RD stated, he added an intervention of protein shakes three times a day. During an interview on 10/19/22 at 01:45 p.m., with RD, RD stated, the doctors practicing at the facility granted him order writing privileges RD stated, he was allowed to write orders to modify therapeutic diets and write orders for nutrition supplements without first obtaining an order…
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 before2022-10-20 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure safe food handling when: 1. Expired, leftover lentil soup that had not been cooled down safely was available for use in the walk-in refrigerator, and 2. The ice machine dispenser located in a kitchenette was not clean. As a result, residents were placed at risk for developing a food borne illness. Findings: 1. During a concurrent observation and interview on 10/17/22, at 09:35 a.m., with Sous Chef (SC), in the main kitchen's walk-in refrigerator, was a large pan of prepared potato salad. The SC stated, he cooked thirty pounds of potatoes that morning. SC stated he cooked the potatoes to 165 degrees Fahrenheit (F) and put them in the reach-in freezer for one hour in which they were then 39 degrees F. SC stated he does not write down the cool down process on a cool down log. SC verified the potato salad would be served for lunch that day to include the residents living in the skilled nursing facility. During a concurrent observation and interview on 10/17/22, at 10:26 a.m., with team leader supervisor…
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
$8,278 in federal fines across 1 penalty.
- $8,278 — penalty dated 2025-11-18
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BROWN, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2021 |
| BROWN, MATTHEW | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2021 |
| CLARK, RAMONA | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2019 |
| CURTIS, WILLIAM | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2023 |
| FELLOWS, STEVEN | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2023 |
| GIFFORD, ANDREW | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2024 |
| KERN, BARKLEY | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2022 |
| KUPPERMAN, JEFFREY | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2022 |
| LOVAN, DIANA | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2024 |
| MCCAGUE, BRIAN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 05/01/2016 |
| MCFARLANE, JAMES | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2024 |
| STEVENS, BRUCE | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2024 |
| TOOMEY, CHRISTOPHER | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2019 |
| ZANINOVICH, KATINA | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2018 |
| MONTECITO RETIREMENT ASSOCIATION | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/1975 |
| BROWN, MARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/22/2025 |
| CABERTE, GLYNN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/30/2022 |
CMS files one row per role, so the 19 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the California Medicaid page for homes that do.
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 555023. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-06, 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.