No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

The Win Post-Acute

410 North Winchester Boulevard, Santa Clara, CA 95050 · For profit - Corporation · 133 certified beds · (408) 248-3736 Medicare & Medicaid certified

Call the home — (408) 248-3736 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0607) — most recent May 2024Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0607) — most recent May 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2375 Forest Ave · (408) 243-8333 · Call to confirm hours
Pharmacy
200 N Winchester Blvd · (408) 247-1894 · Call to confirm hours
Grocery
1993 Bellomy St · (408) 260-0327 · Call to confirm hours
Park
2280 Rosita Ave · (408) 615-2260 · Typically dawn to dusk
Place of worship
402 Knowles Ave · (408) 246-9921

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 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 improved from 3 to 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.5%10.2%15.4%better
Long-stay residents who lose too much weight3.4%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.8%0.9%better
Long-stay residents with a urinary tract infection1.1%1.2%2.0%better
Long-stay residents with depressive symptoms11.1%7.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.6%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened14.7%9.8%16.1%typical
Long-stay residents on antianxiety or hypnotic medication5.9%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers2.5%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control16.1%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 table8.5%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine99.0%93.2%79.4%better
Short-stay residents rehospitalized after admission24.5%23.0%22.6%typical
Short-stay residents with an outpatient ER visit6.8%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days1.882.251.67worse
Long-stay outpatient ER visits per 1,000 resident days1.051.571.80better

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.

61.9% 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 214 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.9%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
40.9%U.S. median 56.6%
Met the expected recovery
0.55U.S. median 0.31
Therapy hours / resident / day
0.29hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 40.9% 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 71 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF61.9%CMS range 54.7–68.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.5–13.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge40.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge49.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge46.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.5%100.0%Oct 2024–Sep 2025CMS 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 discharge96.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.4%CMS range 5.3–11.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.351.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.06
RN hours/ resident / day
0.60
LPN hours/ resident / day
2.35
Aide hours/ resident / day
4.01
Total nurse hours/ resident / day
0.94
RN hoursweekends
45.6%
Total nursing turnover
61.8%
RN turnover

How full it usually is: this home is certified for 133 beds and averages 131.0 residents a day — about 98% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 4.01 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.06 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 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 3.72 hrs/resident/day on weekends vs 4.13 on weekdays — 10% thinner on weekends. RN hours go from 1.10 to 0.94 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

9
deficiencies at the latest standard inspection (2025-05-09)
1
at the previous standard inspection (2024-02-08)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

35 citations, most serious first. The 12 most serious are shown; the remaining 23 are one tap away and print in full.

  • Actual harm · G2024-05-30 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, one of two sampled residents (Resident 1) was not free from physical abuse when Resident 1 was found in bed with multiple bruises to the face and arms, swelling on the bridge of the nose and right eyebrow, a cut on the lower lip, blood in the mouth, on the lips, and on the fingers, and chipped teeth. Resident 1 passed away, and the immediate cause of death was documented as, Blunt force injury [injury caused by forceful impact from an object without sharp edges or points] of head complicating hypertensive [having high blood pressure] and atherosclerotic cardiovascular disease [heart disease involving plaque buildup in the arteries]. Findings: Review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE], and had diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually caused by infection), chronic obstructive pulmonary disease (COPD, a disease that causes obstructed airflow from the lungs), severe protein-calorie…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2021-06-11 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their written abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) policy for one of 24 sampled residents (Resident 14) when certified nursing assistant A (CNA A) continued to provide direct care for activities of daily living (ADLs, such as bed mobility, transfer, dressing, toileting, bathing, personal hygiene, locomotion on unit, and locomotion off unit), had interactions with Resident 14 during weights monitoring and assistance with social dining after an abuse incident investigation when Resident 14 alleged CNA A committed verbal abuse. These failures resulted in Resident 14's emotional distress and social isolation. Findings: Review of Resident 14's undated face sheet indicated she was admitted on [DATE], with diagnoses of diabetes (increase in blood sugar), hemiplegia (paralysis of one side of the body), muscle weakness, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-03-24 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 care and services in accordance with professional standard of practice for one of two residents (Resident 1) when nursing staff failed to follow up an order for a medication.This failure had the potential for negative health outcomes related to not receiving prescribed medication as ordered.Findings:Review of Resident 1's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia (BPH, enlargement of the prostate gland [part of the male reproductive system], type II diabetes mellitus (high levels of sugar in the blood), wedge compression fracture of first lumbar vertebra (collapse of the bone in the spine).Review of Resident 1's physician's order, dated 11/11/25, indicated Finasteride 5 milligrams (mg, unit of measurement) tablet to give 1 tablet by mouth one time a day for BPH.Review of Resident 1's Medication Administration Record (MAR), indicated the medication Finasteride was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-28 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1). This failure had the potential to delay abuse investigations and compromise Resident 1's safety.Review of Resident 1's medical record indicated he was admitted on [DATE] and had the diagnosis of spinal stenosis (the space inside the bones of the spine gets too small), anxiety disorder (a mental health condition), difficulty in walking, and muscle weakness.Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/1/25, indicated his Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (BIMS score of 13-15 indicates cognitively intact).During a telephone interview with Resident 1 on 6/3/25, at 12:01 p.m., he stated that he was assaulted by his co-resident and did not feel safe in the facility. Resident 1 stated that his co-resident…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to follow professional standards of practice for oxygen administration for three of nine residents receiving oxygen therapy in the facility when: 1. Resident 20 was administered the wrong dose of oxygen. 2. Resident 49 was administered oxygen without a doctor's order. 3. Resident 16 was administered the wrong dose of oxygen. These failures had the potential to negatively affect Resident 20's, Resident 49's, and Resident 16's health. Findings: 1. During a concurrent observation and interview on 5/5/25, at 1:17 p.m., with Registered Nurse (RN) A, in Resident 20's room, Resident 20 was observed wearing a nasal cannula (plastic tubing which supplies oxygen from a machine). RN A stated, she saw Resident 20s oxygen set to between 2.5 and 3 liters (measure of oxygen give to patient per minute). RN A stated, she will lower it, the order is for 2 liters for Resident 20, it should be at 2 liters per the doctor's order. During a review of Resident 20's Order Summary Report dated 5/8/25 indicated, Resident 20 had an order 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-09 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    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 40 out of 69 Certified Nursing Assistants (CNAs) who have worked at the facility for over one year were reviewed annually for a performance review per federal regulation. This failure resulted in the facility being unaware of 40 CNA's performance through the prior year. This failure also had the potential for CNA's performance to be below the standard or practice for patient care. Findings: During a review of CNA I's employee file, undated, employee file indicated, no annual performance review was documented. CNA I's hire date was 9/29/2021 During a review of CNA J's employee file, undated, employee file indicated, no annual performance review was documented. CNA J's hire date was 1/12/2017. During an interview on 5/07/25, at 1:18 p.m., with the Director of Staff Development (DSD), the DSD stated, she took over the position of DSD as interim for the last two weeks. DSD stated, I do not know what the prior DSD's process was, but we looked in her desk and did not find any annual performance reviews for the CNAs.…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-09 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure accurate accountability of controlled medication (medication with high potential for abuse and addiction) when random controlled medication use audit for three of twelve residents (Residents 93, 3 and 87) did not reconcile when: 1. The medication was documented on the Medication Administration Record (MAR, used to document medications taken by each individual) to indicate they were administered to Resident 93 but was not signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications). 2. The medication was signed out of the CDR but not documented on the MAR for Resident 87 and Resident 3. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications. Findings: 1. The Controlled Drug Record (CDR) for twelve residents receiving controlled medications were requested for review during the survey. A review of Resident 93's clinical record indicated she had a Physician order for Hydrocodone-Acetaminophen…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-09 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure 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

    Based on interview and record review, the facility failed to ensure one of 35 sampled residents (Resident 34) was free from inappropriate and unnecessary medication use when the medication Midodrine HCI (to treat low blood pressure) was given outside of the ordered parameters. This failure had the potential for causing harm to Resident 34's health and well-being. Findings: During review of Resident 34's medication administration record (provides a comprehensive, organized record of each medication administered to a patient) (MAR), dated May 2025, the MAR indicated Resident 34 received Midodrine HCI 5 milligrams (a unit of measure) (Mg) on 5/8/25 when the blood pressure (refers to the force of circulating blood against the walls of blood vessels. Blood pressure is measured in two values: systolic [highest pressure during a heartbeat] and diastolic [lowest pressure between heartbeats]) was 126/68. During review of Resident 34's orders dated 3/4/25, the order indicated Midodrine HCl oral tablet 5 MG, one tablet by mouth three times a day for hypotension, hold for SBP (systolic blood…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-09 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to identify the lack of annual performance reviews for Certified Nursing Assistants (CNAs) in their Quality Assurance Performance Improvement Plan (QAPI- a plan developed by the facility with the goal of improving conditions in the facility) when monitoring of employee files was not documented as reviewed for regulatory compliance, per the QAPI monitoring plan. As a result, the facility did not identify 40 of 69 CNAs employeed by the facility did not have a documented annual performance review. (see F730). Findings: During a review of the facility's QAPI Plan, updated 2017, QAPI plan indicated, Quality Surveillance Data.Education/In-Service Tracking, Responsible for Review/reporting to Committee Director of Staff Development, Action Plan(s) required for: Federal/State required in-services not completed per regulations, personnel files audits that result in negative findings. QAPI Plan indicated, Random personnel file reviews should occur quarterly to determine compliance with training and documentation requirements as well as…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff were implementing infection prevention practices when: 1. One of four Certified Nursing Assistances (CNA) failed to perform hand hygiene between residents during dining; 2. Resident 309's intravenous (IV, to deliver a medication into a vein) tubing tip left uncapped when not in use. During an observation on 05/06/25 at 12:53 p.m., Certified Nursing Assistant (CNA) F, was in the dining room sitting between Resident 5 and Resident 44 feeding them both lunch without cleaning her hands between Residents. During an interview on 05/06/25 at 3:07 p.m., CNA F stated, She washes hands prior to feeding the residents but does not clean hands between residents when feeding two residents at the same time. Review of the facility's policy and procedure titled Hand Hygiene, dated 5/29/24 indicated, Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .Between…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to revise the care plan for two of 15 residents (Resident 34 & 74) when there was no evidence the facility reviewed or revised the care plan with new recommendations to prevent the Resident from falling again. This failure had the potential to result in further falls and/or injury. Findings: 1. During a review of Resident 34's Fall Report Incident dated 2/21/25, it indicated Resident 34 had a fall on 2/21/25 at 4:30 p.m. During a review of Resident 34's care plans, dated 11/25/24 last revision, indicated no care plan following the 2/21/25 fall or revisions to the previous care plan. During an interview on 5/8/25 at 1:31 p.m. with the Director of Nursing (DON), she stated, the care plan was not updated after the fall. Review of the facility's policy and procedure titled, Fall Prevention and Response, dated 8/2023, indicated Facility will monitor effectiveness of planned fall prevention interventions no less often than quarterly and modify interventions when necessary, such as following a significant COC or fall accident.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 services were provided to prevent and/or heal pressure ulcers (damage to the skin or underlying tissue as a result of prolonged pressure) for one of eight sampled residents (Resident 308) with pressureulcers when staff did not follow physician's order for heel protectors (device applied to the feet to minimize pressure on the heels). This failure had the potential to result in worsening of resdient 308's pressure ulcers. Findings: Review of Resident 308's clinical record indicated he was admitted on [DATE] with diagnoses including heart failure (a condition in which the heart doesn't pump blood as well as it should), pancytopenia (abnormally low amounts of all three types of blood cells, red, white and platelets), encephalopathy (disease that affects brain function), and muscle weakness. Review of Resident 308's clinical record indicated a physician order for right and left heel skin barrier film as needed every shift for pressure…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 23 citations
  • Potential for harm · Dcited before2025-05-09 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure expired medication was removed in one of three medication carts (med cart AA)) when a bottle of Mirtazapine (used to treat depression [a mood disorder characterized by persistent sadness and a loss of interest in activities]) 15 milligrams (mg, unit of measurement) with expiration date of [DATE] was identified. The failure had the potential for residents to receive medications with reduced potency. Findings: During an inspection of the med cart AA and interview with Licensed Vocational Nurse (LVN) B on [DATE] at 12:08 p.m., a bottle of Mirtazapine was found in the medication cart that expired on [DATE]. LVN B confirmed that the medication has expired and should have been removed. During an interview on [DATE] at 2:20 p.m., with the Director of Nursing (DON), the DON stated the expired medication should have been removed from the medication cart. During a review of the facility's Disposal/Destruction of Expired or Discontinued…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 develop and implement a comprehensive person centered care plan for one of eight residents with the potential for skin problems when the facility failed to develop and implement Resident 49's care plan for preventative foot care. This failure had the potential for Resident 49's feet to deteriorate clinically. Findings: During an interview on 5/5/25 at 9:05 a.m., with Confidential Friend (CF) G, CF G stated, they saw Resident 49's feet and believes her care plan needs to be adjusted, because her toe nails are long and they need to do something about them. CF G stated, Resident 49 had fungal infections in her feet, in the past and if they don't keep them clean it will happen again. During an observation on 5/6/25, at 8:21 a.m., in Resident 49's room, Resident 49's feet were noted to have skin buildup to both feet, with thickened, discolored and longer than average toe nails. During a record review of Resident 49's medical diagnoses list, dated 5/6/25, the list indicated, Resident 49 was diagnosed with Type 2…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-08 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, the facility failed to ensure 2 of 6 medication carts on 1 of 4 halls were not left unlocked and unattended. Findings included: Review of a facility policy titled, Medication Storage in the Facility, updated in August 2019, revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy further indicated, Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. An observation on 02/07/2024 at 6:16 AM revealed there were two unlocked medication carts on the 100-Hall. Cart 1A was located between room [ROOM NUMBER] and room…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-26 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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

    Based on interview and record review the facility failed to follow standards of care in obtaining and implementing physician's orders for the treatment and monitoring of skin tears (separation or tear in the skin commonly resulting from bumping or moving) for one of three sampled residents (Resident 1). Resident 1 sustained skin tears and physician's orders for treatment were not obtained and carried out. This failure resulted in the lacked of consistent monitoring of the wound status and had the potential for the skin tears to not optimally heal. Findings: Review of Resident 1's Change in Condition Evaluation, dated 5/3/23 at 4:09 p.m., indicated the resident had a new skin tear to his left elbow and a message was sent to the physician. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool that addresses and plans care of a resident's condition) form, dated 5/31/23 at 6 p.m., indicated a staff from an ambulance company reported the resident had sustained a skin tear and a primary care provider recommended treatment. During an interview…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-26 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 medically-related social services was provided for one of three sampled residents who lost their dentures (Resident 1). There was no documentation of the dentures being lost, no social services documentation of a discussion with a family member regarding how to proceed to replace the loss and no policy addressing under what circumstance the facility was responsible. This failure placed the resident at risk for weight loss, oral discomfort, and general well-being. Findings: Review of Resident 1's Inventory of Personal Effects form, signed on 1/7/23 indicated the resident had one lower denture. During an interview on 7/31/23 at 3:30 p.m., the director of social services (SSD) recalled Resident 1's lower dentures was lost, and he informed a family member the insurance will not cover the cost of the replacement unless the remainder of the resident ' s lower teeth were extracted. The family member then stated to the SSD she did not want the resident to go through the process and to leave things as it was. The SSD…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-06-11 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for five of 24 sampled residents (Residents 8, 64, 87, 99 and 309) and 2 non-sampled residents (Residents 108 and 84) when: 1. For Resident 64, dressing changes and flushes were not performed for a PICC line; 2. For Resident 8, facility staff administered oxygen without a physician's order; 3. For Resident 87, licensed nurses did not follow the physician order for oxygen administration; 4. For Resident 99 and Resident 308, fluid intake and output were not monitored; and 5. Medications were left on top of the medication cart unattended and the medication cart was unlocked. These failures had the potential to compromise the residents' health and well-being. Findings: 1. During an observation on 6/7/21 at 9:48 a.m., Resident 64 had a peripherally inserted central catheter (PICC, a thin, soft, long catheter [tube] that is inserted into a vein in arm, leg or neck…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-06-11 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the ADDS (Automated Drug Delivery System) daily temperature and cycle count was monitored and recorded to ensure the accurate accountability of controlled substances (CS, medications having a high risk for abuse and addiction) for 1 of 3 residents (Resident 71, non-sampled). These failures could result in administering unsafe and ineffective medications to residents and the abuse of controlled medications. Findings: 1. During a concurrent interview and record review of the ADDS Daily Temperature and Cycle Count log on 6/10/2021, at 10:30 a.m., with the director of nursing (DON), indicated record each daily temperature reading, ADDS gauge and ADDS room or immediate area where the ADDS is located and complete at least one dailycycle count and record the signatures of the two attending nurses. Review of the monthly ADDS logs from January 2021 to June 2021, indicated ADDS Temperature and Cycle Count log were not monitored and recorded on the following days: 1/1, 1/2, 1/8, 1/9, 1/12, 1/14, 1/16,1/22/21,1/23/21, 1/24/21,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-11 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of 24 sampled residents (Residents 99, 310, and 44) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. For Resident 99 there was no specific target behavior for the use of Wellbutrin (an anti-depressant medication); 2 Resident 310's remeron did not have appropriate indication and no specific target behavior for the use of fluoexitine (Prozac, an anti-depressant); 3. For Resident 44, there was no specific target behavior to monitor Seroquel (an antipsychotic medication to treat mental and mood conditions) and Depakote (a medication to treat seizures and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic high). These failures could result in the lack of adequate monitoring and unnecessary medications for the residents, which had the potential for increased risks associated with…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-11 · tag F0801 — pattern
    Employ 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 staff with the appropriate competency and skills to carry out functions of the food and nutrition service when the dietary manager (DM) did not provide in-service to the kitchen staff regarding the proper procedures to sanitize food contact surface areas. This failure could affect proper washing and sanitation that could cause foodborne illness to the residents in the facility. Findings: During an observation and interview with the kitchen aide (KA) on 6/8/21 at 10:38 p.m., KA was asked to demonstrate the sanitation process using the sanitizer strip dipped into sanitized water for two seconds and then compare the color to the chart. The KA stated she needs to dip it for 15 seconds and the color result was 400 parts per million. During a concurrent interview with the DM, she stated the staff needs training regarding the sanitation process. The DM stated the proper strength for sanitization process was 200 parts per million. During an interview with the DM on 6/9/21 at 10:17 a.m., she stated there was no…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-11 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when: 1. wet pans were stored under the preparation table; 2. the coffee maker did not follow the daily cleaning per the manufacturer's guide; 3. there were undated open bag of macaroni and undated opened bag of pasta; 4. ice build-up in the freezer; 5. water leak on the dishwasher sink; 6. no air gap on the two compartment sink; 7. handwashing sink temp below 100 F 8. the top of the oven was sticky to the touch. These failures had the potential to cause foodborne illness (illness resulting from contaminated food) to the residents who recieved food from the kitchen. Findings: 1. During an initial kitchen observation on 6/7/21 at 8:24 a.m., wet pans were stored under the preparation table. During a concurrent interview with the registered dietician (RD), she stated the pans should have been stored when dry. Review of the facility's policy, Dishwashing -Machine Operation, indicated to air dry all items. 2. During an initial kitchen…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-06-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Resident 308's urinary bag was touching the floor; 2. Certified nursing assistant H (CNA H) and the licensed physician (LP) did not properly wear the N95 (a high filtering mask); 3. Staff did not know the procedure for point-of-care testing (POC, rapid test); 4. An isolation gown had a sticky material; 5. Certified nursing assistant Q (CAN Q) did not wear an isolation gown when transferring a resident in the yellow zone; 6. A resident was not wearing a facemask while being wheeled in the hallway and, 7. Resident 8 and Resident 109's oxygen cannulas were left hanging on the oxygen concentrator (device that concentrates the oxygen from a gas supply). These failures could result in the spread of infection and cross-contamination that could affect the 116 residents that reside in the facility. Findings: 1. During an observation on 6/7/21 at 10:25 a.m., Resident 308 was in bed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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 needs were accommodated for six of 24 sampled residents (14, 31, 68, 28, 52, and 25) when the call light devices were not within reach. This failure had the potential for a delayed response and not meeting the resident needs. Findings: 1. Review of Resident 14's undated face sheet indicated she was admitted on [DATE], with diagnoses of diabetes (increase in blood sugar), hemiplegia (paralysis of one side of the body), muscle weakness, and hypertension (increase blood pressure). Review of Resident 14's minimum data set (MDS, an assessment tool) dated 3/23/21, indicated she had a brief interview for mental status (BIMS, cognitive status) score of 15 (a score of 15 means cognitively intact), required staff assistance for bed mobility, transfer, dressing, eating, toilet, bathing, locomotion on unit, locomotion off unit, and personal hygiene. During an observation of Resident 14 on 6/7/21 at 9:20 a.m., Resident 14 was lying on the bed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 comfortable and safe temperature levels for five of five rooms (Rooms A, B, C, D, E) when room air temperatures were not maintained in the range of 71 Fahrenheit (F, a scale of temperature) - 81 F. This failure had the potential to result in an unsafe environment for residents. Findings: During an interview on 6/7/21 at 11 a.m. with Resident 78, she stated this room is always cold. During an interview on 6/8/21 at 8:10 a.m., Resident 259 stated his room was cold and it was very cold last night. Resident 259 stated It was always cold in this room. During an interview and observation on 6/8/21 at 8:30 a.m. with the Maintenance Supervisor (MS), the MS checked the air temperature with a thermogun (a device to check room temperature). The temperature for room A was 68 F, room B was 65 F, room C was 66 - 70 F, room D was 65 - 67 F, room E was 69 - 70 F. During an interview on 6/8/21 at 8:55 a.m. with registered nurse A (RN A), she stated It was not warm, and she wears her jacket. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-11 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 interview and record review, the facility failed to ensure appropriate treatment and services for one of 24 sampled residents (Resident 87) when restorative nursing aide (RNA, helps residents to gain an improved quality of life by increasing their level of strength and mobility) program was not followed after the rehab therapy evaluated Resident 87. This failure had the potential for Resident 87 to decline in activities of daily living (ADL's such as bed mobility, transfer, personal hygiene, toileting, and bathing) and prevent contractures. Findings: Review of Resident 87's clinical record indicated he was admitted [DATE] with diagnoses of muscle spasm, muscle wasting and atrophy, contracture hand, contracture knee and contracture joint. Review of Resident 87's minimum data set (MDS) dated [DATE], indicated he had functional limitation in range of motion both upper and lower extremities. Review of Resident 87's physical therapy daily treatment note dated 12/8/2020, indicated Resident 87's was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-11 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 gastrostomy tube (GT, a device surgically inserted into the stomach through the abdomen used to supply food, fluids, and medications) placement was checked prior to administering medication for one of 28 opportunities (Resident 104). This failure had the potential to compromise the resident's care and could cause health complications. Findings: During an observation on 6/7/21, at 12:00 p.m., while in Resident 104's room, Licensed Vocational Nurse E (LVN E) was administering medication to Resident 104, inserted a syringe in the GT, then pulled the plunger. No gastric residual (volume of fluid remaining in the stomach) was observed. LVN instilled a few amounts of air, flushed the GT with water, then proceeded with the medication administration. LVN did not check the GT placement. During an interview on 6/10/21 at 3:00 p.m., LVN E acknowledged that she did not check the GT placement prior to administering Resident 104's medication. LVN E further stated that she should check the GT placement using 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-06-11 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store and label medications and biologicals in accordance with the manufacturer's instructions and the facility's policy and procedure when: 1. One opened multi-dose vial (medication, usually in liquid, intended for more than one dose of medication) was found without an open date in the medication room; 2. One opened inhaler without an open date and one eye solution bottle were being used past the discard dates were found inside the medication cart in Station 4; and 3. One opened vial of insulin (medication to treat high blood sugar) with no open date and one eye solution bottle were being used past the discard dates were found inside the medication cart in Station 3. The deficient practices had a potential for residents to receive medications with unsafe and reduced potency from being used past their discard dates, and medication errors due to medications not being labeled, which could lead to unsafe and ineffective medications for residents. Findings: 1. During an inspection of the medication room in…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-11 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to follow the planned menu for renal diet and the cook did not communicate to the dietary manager (DM) regarding the change of the planned menu. This failure had the potential to result in the decreased nutrient intake intended to the residents on renal diet. Findings: During a trayline (an assembly line type food service) observation on 6/8/21 at 11:44 a.m., white rice and pasta were served for the renal diet. During a concurrent interview with the DM, she confirmed the menu for renal diet was buttered corn but it was not followed. The DM also stated the cook did not communicate they did not have buttered corn. During a concurrent interview with the registered dietician (RD), she stated the plain white rice, pasta, and buttered corn had different nutritional value. RD also stated the cook should have communicated with the dietary manager. Review of the facility diet spread sheet dated 4/26/21, indicated buttered corn to be served for the renal diet.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-11 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 accommodate food preferences for one of 24 sampled residents (Resident 36) when Resident 36 was served food to which he had allergies and disliked. This failure had the potential to affect his physical and medical conditions. Findings: Review of Resident 36's clinical record indicated he had diagnoses of acute respiratory failure, diabetes (increased blood sugar), and hypertension (increased blood pressure). Review of Resident 36 minimum data set (MDS, an assessment tool) dated 4/8/21, indicated Resident 36 had a brief interview for mental status (BIMS, cognitive status) score of 15 (a score of 15 means cognitively intact), required assistance for bed mobility, transfer, toileting, and personal hygiene. During a dining observation and interview with Resident 36 on 6/7/21 12:31 p.m., Resident 36 was not eating and the lunch tray had pasta. Resident 36 stated he would vomit if he ate the pasta. Review of Resident 36's dietary slip dated 6/7/21, indicated Resident 36's allergy or dislike was pasta. During 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-11 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to properly dispose the garbage when the garbage bag was opened and the garbage container lid was not closed. This failure had the potential to attract pest and transfer harmful microorganism to food leading to foodborne illness to the residents. Findings: During an observation with the dietary manager (DM) on 6/7/21 at 8:48 a.m., there was an opened garbage bag with used food containers and the garbage container lid was open. During a concurrent interview with the DM, she stated the garbage bag should have been closed and the garbage container should have been closed. Review of the facility's 2/2009 policy, Garbage and Rubbish Disposal, indicated to maintain a sanitary and safe environment through effective disposal of garbage and rubbish. Outside dumpsters provided by garbage pickup services must be kept closed.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-06-11 · tag F0912 — isolated
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure multiple bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and service the residents receive. Findings: Rooms No. Beds/Rm. Sq.Ft./Res. 301, 302, 303 2 71.5 304, 305, 309 2 71.5 311, 312, 314 2 71.5 During the survey, residents were observed in their rooms. Nursing care and services were not impacted by the shortage of space. The closets and storage were sufficient to accommodate the needs of the residents. During the survey, interviews were conducted to determine if there were any problems or issues with the lack of space or privacy. The residents and staff verbalized no complaints or concerns regarding space and privacy. Recommend the waiver remains in effect.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-11 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make 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 — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to follow their policy to store chemicals when a housekeeping cart was left opened in the resident hallway. This failure had the potential to compromise the health and safety of the residents. Findings: During an initial tour on 6/7/21 at 1:152 p.m., it was observed that an unattended and unlocked housekeeping cart contained chemicals. Two residents were observed walking in the hallway while the housekeeping cart was open. During an observation and interview with the case manager on 6/7/21 at 1:53 p.m., she stated the housekeeping cart should have been locked while unattended. Review of the facility's 6/2016 policy, Always Lock Door, indicated to store chemicals in a lock-box when not using them.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-05-09 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interviews, the facility failed to ensure all multiple-resident bedrooms provided at least 80 square feet per resident for 9 of 60 rooms observed. This failure had the potential for Residents in rooms #301, #302, #303, #304, #305, #309, #311, #312, and #314 to have less space available for daily care and assistance. Findings: During observations from 5/5/25 to 5/9/2025 in rooms #301, #302, #303, #304, #305, #309, #311, #312, and #314., each room was a two-resident room and measured 13 feet by 11 feet, resulting in a total square footage of 143 square feet, or 71.5 square feet per resident. During the observation, residents reported they had plenty of space and did not have concerns with the size of their rooms. During an interview on 5/5/25 at 8 am with the Administrator, the Administrator, stated social services asks the residents or their families each quarter if there were any problems with the room size and none had been reported. The Administrator indicated the smaller room size did not inhibit resident care, and the facility has a room waiver.

    Environmental Deficiencies · Waiver has been granted
  • No harm found · Bcited before2024-02-08 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure all multiple-resident bedrooms provided at least 80 square feet per resident for 9 of 60 rooms observed. Findings included: During observations on 02/08/2024 from 2:05 PM to 2:12 PM, Maintenance Supervisor (MS) #4 measured Rooms #301, #302, #303, #304, #305, #309, #311, #312, and #314. Each room was a two-resident room and measured 13 feet by 11 feet, resulting in a total square footage of 143 square feet, or 71.5 square feet per resident. During the observation, residents reported they had plenty of space and did not have concerns with the size of their rooms. During an interview on 02/08/2024 at 2:26 PM, Certified Nursing Assistant (CNA) #5 indicated she had plenty of space in the rooms to get her work done. During an interview on 02/08/2024 at 2:32 PM, CNA #6 indicated there was plenty of space in the rooms, and she had no problems. During an interview on 02/08/2024 at 2:54 PM, the Director of Nursing (DON) stated the required room space was 80 square feet per resident. The DON further stated the rooms had enough…

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

    Environmental Deficiencies · Waiver has been granted

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to SPYGLASS HEALTHCARE — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 53.1+1.9 vs chain
Health inspection 4 of 52.6+1.4 vs chain
Staffing 3 of 52.9+0.1 vs chain
Quality measures 5 of 54.7+0.3 vs chain
The other 8 homes this chain runs (chain average 3.1★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
SPYGLASS HEALTHCARE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/01/2025
MCCORMACK, RYANIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR40%since 08/01/2025
O'SHEA, BRADYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST5%since 08/01/2025
OSCHEROWITZ, AVISHAIIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 08/01/2025
AWERBUCK, MATTHEWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2025
ESTANILLA, MYRTLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2025
GREEN, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2025
KIKUTA, BRADLEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2025
LAGLIBA, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2025
LUISTRO, ROXANNEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2025
SAM, SOEUNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2025
TORRES, ARELIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2025

CMS files one row per role, so the 22 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$24.2M
Net patient revenuemost recent cost report
+9.0%
Operating marginrevenue minus expenses
$2.9M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 7%Medicare 20%Other / private 73%

This home reported $2.9M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$537per resident / day
operating cost
$16,326per month
≈ monthly operating cost
$590per day
avg. revenue, all payers

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

What families pay in CA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055645. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-09, 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 →

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.

What to do next