Valle Verde Health Facility
900 Calle De Los Amigos, Santa Barbara, CA 93105 · Non profit - Corporation · 80 certified beds · (805) 883-4000 Medicare & Medicaid certified
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)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
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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 held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.8% | 10.2% | 15.4% | typical |
| Long-stay residents who lose too much weight | 7.6% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.5% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.5% | 1.6% | 3.3% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 24.7% | 9.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.7% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 4.3% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 22.0% | 10.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.6% | 12.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 97.4% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.1% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 14.4% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.83 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.34 | 1.57 | 1.80 | better |
‡ 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.
68.8% 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 422 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 72.2% 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 248 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 0.51 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 68.8%CMS range 66.0–72.3 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 7.5%CMS range 5.5–10.2 | 10.7% | Oct 2022–Sep 2024 | better than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 72.2% | 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 | 60.1% | 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 | 63.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.7% | 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 | 93.2% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 97.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.7% | 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 | 1.3% | 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 | 5.1%CMS range 3.1–7.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.84 | 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 80 beds and averages 55.7 residents a day — about 70% occupied, or roughly 24 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.60 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 4.15 hrs/resident/day on weekends vs 5.04 on weekdays — 18% thinner on weekends. RN hours go from 0.76 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2026-06-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to prevent the development of an unstageable (a severe wound where the true depth and extent of tissue damage cannot be determined because the wound bed is completely obscured by dead tissue) pressure ulcer (localized damage to the skin and underlying soft tissue) in one of three sampled residents (Resident 1). Resident 1 was admitted to the facility with a left ankle-foot orthosis boot (AFO - a medical brace designed to support the ankle) status post-surgery and was found with an unstageable pressure ulcer on the left foot approximately 6 weeks later. This facility failure resulted in Resident 1 experiencing pain in the affected area (left foot) with psychosocial fear of losing a limb secondary to existing medical conditions (type 2 diabetes mellitus [Type 2 DM] - disease requiring daily insulin injections to manage blood sugar levels).During a review of Resident 1's medical records, the admission record (AR), dated 6/30/26, indicated an admission date of 4/27/26, for rehabilitation following a left ankle foot fracture…
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 · D2026-01-09 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the POLST (Physician Orders for Life-Sustaining Treatment -a medical document that translates treatment preferences into actionable medical orders) was signed by the Responsible Party (RP- one who has authority to make healthcare decisions) for one of 4 sampled residents (Resident 14).This failure had the potential to result in Resident 14's wishes regarding medical treatment not being followed.Findings:During a review of Resident 14's POLST (Physician Orders for Life-Sustaining Treatment [a medical document that translates treatment preferences into actionable medical orders]), dated 11/10/25, Resident 14 signed the POLST consenting to DNR (Do Not Attempt Resuscitation), Selective Treatment - goal of treating medical conditions while avoiding burdensome measures, Request transfer to hospital only if comfort needs cannot be met in current location, and Trial period of artificial nutrition, including feeding tubes.During a review of Resident 14's H&P (History and Physical) dated 11/11/25, the H&P indicated, 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 before2026-01-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to:1.Develop a care plan and interventions for hearing impairment for one of two sampled residents (Resident 8). This failure had the potential for Resident 8's hearing impairment to worsen and thus impact the resident's quality of life.2.Implement care plan interventions for Resident 11 related to access to call light and repositioning in bed. This failure had the potential for Resident 11 not to receive the necessary care needed. 1.During a record review of Resident 8's comprehensive assessment, dated 12/04/25, this indicated Resident 8 was assessed to have hearing impairment.During an observation on 01/07/26 at10:55 a.m. Resident 8 was in the common area near the activity room reading a newspaper with no hearing aids. When greeted, Resident 8 just stared at this surveyor.During an interview on 01/08/26 at 10:45 a.m. with Resident 8's Responsible Party (RP), the RP stated Resident 8 can be moody if not wearing the hearing aids and can…
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 · D2026-01-09 · 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 Number of residents sampled: 4Number of residents cited: 1Based on observation, interview and record review, the facility failed to follow a mechanically altered diet order for one unsampled resident (Resident 53), who had dysphagia (difficulty swallowing), when staff served Resident 53 coffee without thickener.This failure had the potential to cause swallowing discomfort and/or aspiration (the accidental entry of a fluid or food into the airway or lungs) for Resident 53.During a review of Resident 53's clinical record, it indicated that Resident 53 was admitted to the facility on [DATE] with diagnoses that included Bell's Palsy.During an observation on 1/6/26 at 12:18 p.m. in the resident dining room, Resident 53 was served a meal tray by staff. As Resident 53 started eating without assistance, another staff member brought Resident 53 a cup of coffee, from which Resident 53 sipped.During a review of Resident 53's menu and attached strip of paper with diet order found next to meal tray, it indicated that…
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 before2026-01-09 · 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:1. The Infection Prevention Control and Program (IPCP) standards and policies were reviewed at least annually. This failure had the potential for the facility to implement outdated infection control standards, policies, and protocols that can lead to an ineffective infection control program2. Staff followed manufacturer's instructions on cleaning and disinfecting a blood sugar monitor machine (glucometer). This failure had the potential for cross contamination of blood transmitted infections. During an interview on 01/08/26 at 11:30 a.m. with Infection Preventionist (IP), the IP stated the IPCP policies and procedures are online and that the Interdisciplinary Team (IDT) was responsible for reviewing the IPCP Policies and Procedures (P&P). The IP was unable to provide an answer as to when the policies should be reviewed and the last date it was reviewed. During the interview on 01/08/2026 at 2:43 p.m. with the Director of Nursing (DON), the DON confirmed there was no tracking system to determine when 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 · D2026-01-09 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a patient care equipment, a glucometer (a device used for measuring the concentration of glucose in the blood for diabetics), was maintained in a safe operating condition.This failure had the potential to result in false blood sugar readings, compromising the health and well-being of residents.Findings:Based on interview and record review, the facility failed to ensure a glucometer (a device used for measuring the concentration of glucose in the blood for diabetics), was maintained in a safe operating condition.This failure had the potential to result in false blood sugar readings, compromising the health and well-being of residents.Findings:During a concurrent interview and record review on 1/7/26, at 10:01 a.m., a glucometer logbook (logbook where glucometer test check results are listed) for the month of December 2025 was missing glucometer test check result entries from 12/1/25 to 12/17/25. During a concurrent interview and record review on 1/7/26, at 10:01 a.m., with the Infection Preventionist (IP), the IP…
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 · F2025-01-10 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service when the Director of Food and Nutrition Services (referred to as Director of Dining Services (DDS)), albeit was a full time (FT) position, DDS was responsible for not only the main kitchen that provided foodservice for the residents residing in the Health Center (skilled nursing facility), but also responsible for two other foodservice operations located on the Continuing Care Retirement Community (CCRC) campus, community Meals on Wheels, and providing food for another contracted small health facility. DDS failed to demonstrate appropriate skill set related to sufficient managerial monitoring and guidance related to: 1a. TCS foods (Time Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) were not consistently and accurately cooled down to ensure food safety; 1b. An ice machine was not sanitary; 1c. Incomplete cleaning…
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 before2025-01-10 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service when: 1. TCS foods (Time Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) were not consistently and accurately cooled down to ensure food safety. 2. The ice machine, located in a pantry near a nursing station, utilized for residents was not maintained in a sanitary condition. 3. There were unsanitary conditions in the main kitchen related to: 3a. Kitchen floors with build -up of dried food debris. 3b. Floor drains with build- up of dried food debris. 3c. Clean equipment stored on unclean shelves. 4. There was a container of cooked pasta in the walk-in refrigerator in the main kitchen that was not dated. 5. Foodservice equipment was not maintained in good repair as evidenced by leaking pipes, located in the warewashing areas of the main kitchen, in which the water was pooled into a container which could attract pests such as insects and rodents. 6.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-10 · 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 observation, interview, and record review, the facility failed to ensure the Emergency Drug Supply Kit (E-kit) was stocked accurately according to the table of contents. This failure had the potential for residents not to receive necessary medications in case of emergency. Findings: During a concurrent observation and interview on 1/7/25 at 12:30 p.m., with the Infection Preventionist (IP), one unopened E-kit was observed in the medication storage room in station 2 with green colored locks. IP stated green locks indicates E-kit has not been opened by facility staff. The list of contents (on the outside of this E-kit) indicated Keflex (a medication used to treat infections caused by bacteria) 250 milligrams (mg) 8 caps (capsules). The letters 8 caps is crossed out and the number 2 is written next to it, indicating this E-kit contained 2 capsules of Keflex. Upon inspection of E-kit contents, 8 capsules of Keflex 250 mg were observed. IP acknowledged E-kit stock does not match the table of contents. During a review of the facility's Policy and Procedure titled, Emergency Kit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure: 1. Expired items in the medication storage room, medication cart, and treatment cart were discarded and not readily available for staff use. 2. A work order was done when the temperature of the medication refrigerator was below acceptable range. These failures had the potential for residents to receive expired and ineffective medications. Findings: 1. a. During a concurrent observation and interview on 1/7/25 at 2:40 p.m., with Licensed nurse (LN) 1, one vial of Lantus (a medication used to manage blood sugar levels) was stored in medication cart 1B with an open date of 12/1/24 and an expiration date of 12/28/24. Manufacture's instruction on box indicated vial should be discarded after 28 days of opening date. LN 1 acknowledged the Lantus was expired and stated she administered the Lantus to the resident that morning. b. During a concurrent observation and interview on 1/7/25 at 12:01 p.m., with the Infection Preventionist (IP) in the medication room in station 2, a box of budesonide ampules (medicine…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-10 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure 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 planned menu for the therapeutic Mechanical [Mech] Soft Chopped (Level 6) [Level 6 - Soft & Bite-Sized (SB6)] diet (SB6 diet; food may be used when not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow) was developed and prepared in accordance with established national guidelines, IDDSI (International Dysphagia [difficulty swallowing] Diet Standardization Initiative), when the facility's menu modified the Level 6/SB 6 framework by incorporating unsafe foods based on an out-of-date Mech Soft Chopped diet from an obsolete National Dysphagia Diet (NDD). There were seven residents residing at the facility with a Mech [mechanical] Soft diet order that were provided Mech Soft Chopped (Level 6) menus as follows: Resident # (number) 2, Resident #33, Resident #45, Resident #1, Resident # 6, Resident #11, Resident #16. As a result, the facility co-mingled an out-of-date therapeutic diet Mech Soft Chopped (NDD) that was no longer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · Dcited before2024-10-21 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 interview and record review, the facility failed to ensure staff accurately documented pain assessment and management based on Resident 1's care plan after a surgical procedure. This failure had the potential for Resident 1 to have extended and unrelieved pain. Findings: During the review of Resident 1's admission record, this indicated Resident 1 was admitted on [DATE] for an aftercare following joint replacement surgery, and that Resident 1 was responsible to self. During a review of nursing progress notes dated 9/8/24 and time stamped at 8:12 p.m., Licensed Nurse 1's (LN 1) note entry indicated Resident 1 had verbally complained of intermittent (not continuous or steady) pain, number 5 out of 10 in pain scale (indicating moderately strong pain) on her right knee. During a concurrent interview and record review on 10/24/24 at 7:30 p.m., with LN 2, the nursing progress notes dated 9/8/24 time stamped at 8:02 p.m., entry by LN 2 was reviewed. This indicated Resident 1 was able to make needs known 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 · D2024-08-27 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 implement it's policy and procedure, on Handling Controlled Substance, ( prescribed , monitored, controlled narcotics) during discharge of one of two residents (Resident 1). Resident 1 was discharged with the medication Norco, which the resident found to be missing, from his discharged paper works and belongings . Resident then informed and notified the facility . This failure had the potential for drug diversion ( medication used by others aside from the patient ), placing the resident at risk for unaddressed pain with no relief. Findings: Review of the medical record for Resident 1 indicated admission date of 7/30/24 and a diagnosis of post hip replacement . Resident 1 was recuperating from the surgery and discharged on 8/6/24 . Review of a report dated 8/13/24 , indicated on 8/6/24 , Resident 1 was discharged from the facility, escorted by the facility's social services staff member (SS 1) out of the facility main entrance door to a waiting taxi . Resident 1 was going to the airport to catch a flight.…
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 · D2024-07-01 · 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 record review and interview, the facility failed to ensure Resident 1 was wearing a gait belt (a device that helps prevent falls) at time of fall, during Resident 1's initial occupational therapy evaluation. This facility failure had the potential to create an unsafe environment for Resident 1. Findings: During a review of Resident 1's admission Record undated, indicated in part Resident 1 was admitted to the facility on [DATE], with diagnoses including cellulitis (bacterial skin infection) of right lower limb, restless leg syndrome (a condition that causes an urge to move one's legs when resting), and cutaneous abscesses (localized collections of pus that occur within the skin) of the right and left foot. During a review of Resident 1's Progress Notes dated 6/14/24, indicated in part Resident (Resident 1) had a witnessed fall 6/13, while working with OT (Occupational Therapist, OT 1) that resulted in a mildly displaced fx (fracture) to the right ankle. During an interview on 6/18/24, at 11:45 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to demonstrate it implemented individualized care planned interventions for monitoring and recording pain characteristics, for two of two sampled Residents (Resident 1 and Resident 2). This facility failure had the potential for nursing staff to inadequately capture and report to the full extent, Resident 1 and Resident 2's self-reported pain. Findings: During a review of Resident 1's Care Plan Report , undated, indicated in part Resident 1 was At risk for episodes of pain r/t (related to) GI bleed (bleeding that starts in a person's Gastrointestinal tract), polyosteoarthritis (a form of arthritis that affects many joints simultaneously), R (right) wrist fx (fracture), decreased mobility and general pain and discomfort. Resident 1's Care Plan Report further indicated an intervention to Monitor/record pain characteristics Q shift (every shift) and PRN (as needed): Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving…
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 before2024-05-16 · 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 record review and interview, the facility failed to properly secure 60 oxycodone tablets (a Schedule II drug used to treat moderate to severe pain with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) upon delivery from the pharmacy. This facility failure resulted in the facility not being able to account for where the 60 oxycodone tablets went and had the potential to negatively impact Resident 1's pain management treatment. Findings: During an interview on 4/2/24, starting at 1:45 p.m., with the Administrator (Admin 1) and Director of Nursing (DON 1), the Admin 1 and DON 1 were asked to explain the facility's understanding of how the 60 oxycodone pills went missing from the facility. The Admin 1 verbalized on 3/21/24, the pharmacy delivered 60 oxycodone pills and a Licensed Nurse (LN 1) received and signed off for 60 oxycodone pills. The Admin 1 further verbalized the LN 1 took the 60 oxycodone pills, which were contained within two pill packs, containing 30 pills each, and their corresponding narcotic sheets, 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 · D2023-03-01 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 follow up/new Preadmission Screening and Resident Review (PASRR -mental disability assessment ) for Level 1 was done for one of 26 residents (Resident 3). This failure had the potential to result in Resident 3 not being adequately assessed and followed for mental health screening post admission. Findings: Review of Resident 3's clinical record, indicated diagnoses including: hypertension, diabetes, and bipolar disorder (mood diorder with highs and lows) among others. Resident 3's PASRR, dated 8/2/22, for level 1 screening indicated: Level 1-Positive (resident with mental disorder condition). During further record review the document titled, Department of Health Care Services (DHCS) Letter, dated 8/10/22, indicated, unable to complete level II evaluation .stating in part . The individual was isolated as a health or safety precaution . the case now closed. To reopen please submit a new level 1 Screening . During further review of Resident 3's clinical record, no new level 1 PASRR screening was located after 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 before2023-03-01 · 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 observation, interview, and record review, the facility failed to ensure comprehensive person-centered care plans were developed and implemented for three out of 26 sampled residents (Residents 35, 16, and 198) when: 1. Interventions for Resident 35 who had depression (a common and serious medical illness that negatively affects how you feel, the way you think, and how you act, causes feelings of sadness and/or loss of interest in activities you once enjoyed) were not followed and implemented. 2. Resident 16's care plan interventions for depression were not followed. 3. No care plan was developed for Resident 198, who was on contact precautions (everyone coming into a patient's room is asked to wear a gown and gloves prior to patient contact). These failures had the potential for Residents 35, 16, and 198, to not receive the appropriate care and services, based on problem areas identified during admission and current health issues. Findings: 1. During a concurrent observation and interview, on 2/21/23, at 12:00 p.m., with Resident 35, the resident was lying in bed crying,…
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 before2023-03-01 · 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 there were no expired medications. This failure had the potential to result in residents receiving expired medications. Findings: During a concurrent observation and interview, on 2/21/23, at 10:40 a.m., with Licensed Nurse (LN 1), during a review of medication storage room at nursing station two and three, observed one Comfort Pak (CP) 1 Pak expired 12/6/22. Comfort Pak consisted of CP Bisac 10 milligrams (mg) (Bisacodyl a medication to treat constipation) X 1, CP Acetaminophen (pain medication) 650 mg suppository X 4, CP Prochlorper (medication for nausea and vomiting) 10 mg tablets X 6, and CP Hyoscyam(medication for muscle spasms) 0.125 mg Sublingual (SL under the tongue) tablets X 12. LN 1 confirmed, the medications were expired and stated, Yes, it's expired. Sometimes night shift checks the meds, sometimes I would check, and the other nurse and nurses on weekends. During a concurrent observation and interview, on 2/21/23, at 11:15 a.m., with LN 1, during a review of the medication cart 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.
- Potential for harm · Dcited before2023-03-01 · 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 follow its policies and procedures (P&P) on food storage, sanitation of food-contact surfaces when: 1. a) Unlabeled foods were found in dry storage b) Expired food found in walk-in refrigerator 2. Dietary staff failed to demonstrate the correct procedure in testing the concentration level of the sanitizer solution used to sanitize food- contact surfaces. These failures had the potential for expired food to be served to residents and food prepared on unsanitized surfaces, which could contribute to serious food-borne illnesses. Findings: 1. a) During a concurrent observation and interview, on 2/21/23, at 10:15 a.m., with the Director of Dining Services (DDS), the facility's food storage areas were inspected. In the dry food storage room an unlabeled plastic container of breadcrumbs was observed. DDS confirmed that breadcrumbs should have been properly labeled. b) During a concurrent observation and interview, on 2/21/23, 10:13 a.m., with DDS, one of two walk-in refrigerators, contained expired food: pancake…
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 before2023-03-01 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance 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 ensure for two out of 26 sampled residents (Resident 23 and 32): 1. Resident 23's care plan on depression was revised and updated to reflect medication discontinuance when the use of the antidepressant medication (Remeron /Mirtazapine-use to treat feelings of sadness, loss of interest in activities and ADLS, ) was discontinued. This failure had the risk of inaccurate information regarding the use of Remeron on the resident. 2. Resident 23's care plan on weight loss was revised and updated when the resident gained weight. This failure placed Resident 23 at risk for wrong body weight calculation which can affect overall nutritional needs. 3. Resident 23's Restorative Nursing Assistant (RNA) exercises were documented as rendered, not rendered, and the reason not rendered. This failure placed Resident 23 at risk for lack of adequate intervention in regards to ambulation tasks. 4. Resident 32's clinical record had no documentation indicating the wanderguard (alarming device) was checked for functionality. This failure placed…
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 before2023-03-01 · 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 standard infection prevention and control practices were met when: 1) A Certified Nursing Assistant (CNA 1) was observed without an isolation gown on as personal protective equipment (PPE- disposable gowns, gloves, eye wear, shoe wear mask usage to prevent spread of infection), while taking vital signs on a resident (Resident 198), who was on contact precautions. 2) A housekeeping staff (HS 1) was observed collecting trash bags without gloves on. These failures had the potential for the spread of infection among residents, staff, and visitors. Findings: 1) During a concurrent observation and interview, with a Licensed Nurse (LN 6), on 2/21/23, at 3:07 p.m., a PPE cart, which contained disposable gowns, clean gloves, hand sanitizer and a posted signage which indicated, to see nurse before entering the room were observed just outside Resident 198's room. LN 6 verbalized, Resident 198 had been placed under contact precautions (everyone coming into a patient's room is asked to wear a gown and gloves prior…
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 · D2023-03-01 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 safe water delivery when water delivery logs on Legionella (bacteria that can cause a serious type of pneumonia [lung infection]) testing was with missing/incomplete documentation. This failure placed the facility's water delivery at risk for potential spread of Legionella. Findings: 1. During a concurrent interview and record review, on 2/23/23, beginning at 9:15 a.m., with Housekeeping Supervisor (HS), and Building and Grounds Director (BGD), Quarterly logs for Legionella testing, dated 2/15/22, 7/28/22, 9/14/22, and 12/20/22, were reviewed. The quarterly logs indicated the testing was not completed quarterly between 2/22 and 7/22. HS stated. Oh no, you are right. That should have been in May not July. BGD stated,That's not late, that is missed. During a review of the facility's policy and procedure (P&P) titled, Water Management Program, dated 7/01/2017, indicated in part ., The purpose of the Water Management Plan is to define the Safety Program to reduce the risk of injury of residents, team members, family…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to HUMANGOOD — 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.5 | +0.5 vs chain |
| Health inspection | 4 of 5 | 3.6 | +0.4 vs chain |
| Staffing | 5 of 5 | 4.9 | ≈ chain avg |
| Quality measures | 5 of 5 | 4.2 | +0.8 vs chain |
The other 16 homes this chain runs (chain average 4.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| HUMANGOOD NORCAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 03/31/1967 |
| HUMANGOOD | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 05/01/2016 |
| US BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 04/01/2018 |
| BAKER, JUDITH | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2016 |
| BATTISON, WILLIAM | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2016 |
| BROWN, HERMAN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/10/2013 |
| CHRISTOPHERSON, JOANNE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/20/2025 |
| FELLER, IRENE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/26/2021 |
| GRIFFITH, ALAN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/30/2019 |
| HOLMES, MICHELLE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2016 |
| KELLEY, ALBERT | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2016 |
| VANGELISTO, GWEN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/28/2021 |
| COCHRANE, JOHN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/10/2009 |
| GHASSEMI, BETHANY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/21/2019 |
| MCDONALD, ANDREW | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2020 |
| OGUS, DANIEL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/17/1995 |
| HUMANGOOD SOCAL | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/12/1993 |
| BORDOFSKY, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/19/2022 |
| FAIRLEY, TRACIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2026 |
| HANSEN, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/08/2025 |
| HENDERSON, MARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/12/2025 |
| HOLLAND, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2018 |
| PHARMERICA DRUG SYSTEMS LLC | Organization | ADP OF THE SNF | — | since 11/02/2017 |
CMS files one row per role, so the 48 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.
5 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.
This home reported $2.6M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055733. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-09, 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 →
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