Villa Maria Post Acute
425 East Barcellus Avenue, Santa Maria, CA 93454 · For profit - Limited Liability company · 81 certified beds · (805) 922-3558 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (24% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.3% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 4.0% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.5% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 1.6% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 6.2% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 8.3% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.4% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 7.2% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.9% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.9% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 11.8% | 11.2% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.90 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.55 | 1.57 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
57.4% 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 303 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 73.9% 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 138 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 0.57 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.4%CMS range 51.2–61.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 8.3–14.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 73.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 78.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 62.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.7%CMS range 6.7–14.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.36 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 81 beds and averages 74.6 residents a day — about 92% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.37 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.66 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.87 hrs/resident/day on weekends vs 4.58 on weekdays — 15% thinner on weekends. RN hours go from 0.49 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 24% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · Dcited before2025-07-25 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 83) had a qualified licensed nurse perform their initial comprehensive nursing assessment.This failure had the potential for Resident 83 to not have a complete initial comprehensive nursing assessment and not have all their needs met.During a review of Resident 83's admission Record (AR), dated 7/25/25, the AR indicated, Resident 83 was a [AGE] year old, admitted [DATE] with diagnoses including, heart failure (the heart not able to pump enough blood to meet the body's needs), atrial flutter (uncoordinated beating of the heart), diabetes (the body is not able to turn food into energy), and cognitive communication deficit (problems with communication).During a review of Resident 83's Initial admission Record ([IAR] a comprehensive assessment,) dated 4/25/25, the IAR indicated, Neuro/Mental [brain function assessment].EENT [eye, ear, nose, mouth assessment]. Oral Assessment. Cardiovascular System [heart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-25 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure one of one sample residents (Resident 83), had a nursing note recorded in their medical record following the completion of the comprehensive assessment on admission to the facility.This failure resulted in an incomplete record of Resident 83's nursing home stay and had the potential to hinder communication among Resident 83's interdisciplinary team ([IDT], a group of healthcare professionals who work together to achieve resident comprehensive goals).During a review of the facility's policy and procedure (P&P) titled, Admission, dated 2/2023, the P&P indicated, Purpose. Obtain information about the resident to establish baseline data for the MDS and provide the basis for interdisciplinary assessment, care planning, and rehabilitation of each Resident. Licensed Nurses Procedure . Do a complete assessment of body systems and complete admission form and nursing notes.During a review of Resident 83's electronic medical record (eMR), no admission nursing note was found.During an on 7/24/25 at 4:42 p.m. with the Assistant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 6) had an appropriately sized waste bin for safely discarding used personal protective equipment (PPE), a gown worn over clothing for protecting the wearer from infection.This failure had the potential to result in the increased risk of spreading infection to residents, staff, and visitors.During an observation on 7/23/25 at 2:28 p.m. in Resident 6's room, there was a small, beige, uncovered, waste bin overflowing onto the floor with a discarded yellow PPE gown. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 1/2025, the P&P indicated, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals. The facility will use effective methods for the safe storage, transport and disposal of garbage, refuse and infectious waste.During a concurrent observation and interview on 7/23/25 at 2:30 p.m. with a certified nursing assistant (CNA 1) in Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-25 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure two of two sampled residents (Residents 72 and 49) had a comfortable environment when foul smelling dirty linen was left in the linen cart in the hallway. This failure resulted in an uncomfortable living environment. During a review of the facility's policy and procedure (P&P) titled, Environmental Conditions / Environmental Rounds, dated 1/2025, the P&P indicated, It is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.During an interview on 7/23/25 at 10:15 a.m. with Resident 72, Resident 72 stated the smell out in the hallway gets really bad when staff put dirtied linen in the hamper and leave it there. Resident 72 further stated the staff should at least take it down to the end of the hallway.During a concurrent observation and interview on 7/23/25 at 10:56 a.m. with a licensed nurse (LN 1), LN 1 stated there was a bad smell in the hallway. LN 1 pointed towards the blue linen collection bins, waved her hand and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1), when documentation of interventions for a change in condition were not accounted for. This failure had the potential to result in Resident 1 not receiving proper treatment during a change of condition. Findings: During a review of Resident 1's Medical Records (MR), MR indicated, Resident 1 was admitted to the facility on [DATE] with the following diagnoses: palliative care (medical care to improve the quality of life for people with a serious illness), amyotrophic lateral sclerosis (progressive, fatal disease that affects nerve cells in the brain and spinal cord), dysphagia (difficulty swallowing), dysarthria (speech disorder that makes it hard to form and pronounce words due to muscle problems) and anarthria (complete loss of speech), cognitive communication deficit (reduced awareness and ability to initiate and effectively communicate needs), gastrostomy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-06 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure: 1. Pasteurized eggs were used for egg preperations not cooked through completely according to the facility's policy and procedures (P&P). 2. Food was stored properly in accordance with professional standards of food service safety when an uncovered and undated bag of shredded mozzarella cheese was found in the refrigerator and an opened staff personal water bottle was stored in the freezer. 3. Resident food refrigerator temperatures located in the nursing station were monitored daily and corrective actions implemented for out-of-range temperature readings by the food and nutrition representative according to the facility's P&P on foods brought by family or visitor. 4. An appropriate drainage piping material was used to drain the ice machine and an appropriate air gap was maintained between the ice machine and floor drains to prevent contaminated water from backing up into the ice machine should drainage problems arise. These…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-06 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 obtain an informed consent for the use of psychotropic medications (medications which affects mood or behavior) for one of 20 sampled residents (Resident 37). This failure violated Resident 37's right to make an informed decision regarding the use of psychotropic medications and had the potential to result in resident misinformation regarding its benefits and side effects. Findings: During a review of Residen 37's, admission Records, dated 02/28/24, the records indicated Resident 37 was admitted to the facility on [DATE], with admission diagnoses including but not limited to: Other psychotic disorder not due to a substance or known physiological condition, Vascular Dementia (problems with thought processes caused by brain damage from impaired blood flow to your brain), Unspecified severity with agitation, Other specified depressive episodes, and Chronic Post-traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-06 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete and accurately document a Physician Order for Life Sustaining Treatment (POLST - care directives during life threatening situations) and Advance Directive (legal documentation consistent with the known requests or desires of the patient's medical preference) for two of 20 sampled residents (Residents 5 and 37). These failures had the potential to result in the delay of necessary treatment compatible with the legally recognized decision maker wishes during an emergency situation. Findings: During a review of Resident 5's, admission Record, dated 04/20/24, the Record indicated in part, Resident 5 was admitted to the facility on [DATE] with admission diagnoses including but not limited to, Urinary Tract Infection (UTI - an infection in the urinary system of the body), generalized muscle weakness, Type 2 Diabetes Mellitus with other skin complication, and Congestive Heart Failure. During a concurrent interview and record review on 06/04/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-06 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
This is the incorrect tag Based on observation, interview, and record review, the facility failed to follow their policy and procedure regarding loss or theft of resident property. Findings: During an observation on 6/3/24 at 2:10 p.m., a brown wallet containing a driver's license, social security card and military identification was observed in medication cart number one, located in a locked medication drawer. During a concurrent interview and record review on 6/3/24 at 2:15 p.m. with licensed nurse (LN 2), discharged residents in Point Click Care (PCC) (point click care is a cloud-based software platform used by some health care providers to monitor and track patient care) were reviewed. PCC indicated, Resident was discharged AMA (against medical advice) on 9/8/23. LN 2 verbalized, they did not know if the former resident has been contacted, the wallet should not have been kept in the medication cart. LN 2 further verbalized, the wallet should have been taken to social services. During a review of the facility's policy and procedure (P&P) titled, Theft and Loss Policy, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-06 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a significant change in status was comprehensively assessed for one of four sampled residents (Resident 15) using the CMS (Centers for Medicare and Medicaid Services) specified Resident Assessment Instrument (RAI - Resident Assessment Instrument [a standardized tool used to evaluate and document clients in long term care {LTC} settings] process). This failure had the potential to result in compromised quality of care for Resident 15. Findings: During a review of Resident 15's Medical Record, the Medical Record indicated, Resident 15 was re-admitted to the facility on [DATE] from the hospital. The psychologist's progress note dated 4/16/24, indicated, Pt. (patient) was taken off his anti-psych medications recently (when d/c'd [discharged ] from hospital) & he's become increasingly disorganized since then. Physician: please re-start Pt. on his previous level of Seroquel [an antipsychotic medication] that had been working very well. Further record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · D2024-06-06 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR - a federally mandated process to help ensure that individuals are evaluated for a mental illness and/or intellectual disability and are not inappropriately placed in nursing homes for long term care) Level II evaluations (a person-centered evaluation that is completed for anyone identified by the Level I screening as having, or suspected of having serious mental illness, intellectual disability, developmental disability, or related condition) were completed for three of 20 sampled residents (Residents 15, 37 and 66) when: 1. A significant decline in Resident 15's mental health condition was assessed. 2. A positive PASRR Level I (a preliminary assessment for individuals to identify serious mental illness, intellectual disability, developmental disability, or related condition prior to admission to a nursing facility) evaluation was indicated for Residents 37 and 66. These failures 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.
- Potential for harm · D2024-06-06 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the State mental health authority was notified after a significant decline in the mental health condition of one of four sampled residents (Resident 15) was assessed. This failure had the potential to result in Resident 15 not receiving the necessary mental health care and services which had the potential to affect Resident 15's quality of life and resulted in the mental significant change of condition not having been properly screened/evaluated and reported to the state mental authority. Findings: During record review of Resident 15's Psychologist Progress Notes, dated 4/16/24, the Progress Note indicated, Pt. was taken off his anti-psych medication (when d/c'd from hospital) & he's become increasingly disorganized since then. Physician: please re-start Pt. on his previous level of Seroquel that had been working very well. Admitting diagnoses included in part, Psychoses (mental disorder characterized by a disconnection from reality) and Depression (mental state of low mood and aversion to activity). The facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-06 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. A box of expired Povidone-Iodine prep pads. (antiseptic pads saturated with povidone iodine solution to help control bacteria and minimize infection) was discarded. 2. An opened vial of purified protein derivative (PPD - solution used in a skin test to help diagnose tuberculosis [a serious lung infection caused by bacteria]) solution was dated. 3. An open container of glucose test strips (used in a device to measure the amount of sugar in the blood) was dated. 4. Barium Sulfate (a contrast agent used to diagnose disorders of the esophagus, stomach and intestines) stored in the medication refrigerator had a documented physician order for specific resident use. These failures had the potential for the residents to receive expired, ineffective and unprescribed medications and treatments. Findings: During an inspection on [DATE] at 9:30 a.m. of the medication storage area, the following were observed: 1. One box of expired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-06 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and record review, the facility failed to: 1.Store Schedule II Drugs (schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) under double lock per facility's policy and procedure (P&P). 2.Sign the drug count sheet after administering medication per facility P&P. 3.Maintain refrigerator temperatures. These failures had the potential to result in (1) schedule II drugs being available to residents and visitors; (2) for drug diversion; and (3) medications to not be effective. Findings: During an inspection on 6/3/24 at 9:30 a.m. of the medication storage area, the following were observed: 1.Schedule II Drugs were not stored under double lock. During a review of the facility's P&P titled, Medication Administration, dated 11/2023, the P&P indicated, Medications listed in schedules II, III, IV, and V are stored under double lock in a locked cabinet or safe designated for that purpose, separate from all other medications. 2.One controlled drug count…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to implement transmission-based precautions (infection control measures specific to how an infection is spread) for one of 20 sampled residents (Resident 5) when the resident was diagnosed with a known Multidrug Resistant Organism (MDRO - a germ that is resistant to many antibiotics). These failures had the potential to result in the spread of harmful microorganisms to staff, residents and visitors. Findings: During a concurrent interview and record review on 06/05/24 at 10:00 a.m. clinical record with Assistant Director of Nursing (ADON), Resident 5's History and Physical (H&P), dated 04/20/24, was reviewed. Resident 5's H&P indicated, . Patient was found to have UTI [urinary tract infection] with history of ESBL ., .continue with contact isolation . ADON acknowledged Resident 5 was colonized (presence of bacteria without causing an active infection but can be spread to others) with Extended-spectrum beta-lactamases (ESBL - enzymes (special proteins) that are made from bacteria that are resistant to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-09 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to notify the resident representative (RR - person designated as being responsible for another person's medical and/or financial decisions) of one of two sampled resident (Resident 1) after a change of condition (CoC) when Resident 1 underwent debridement (removal of damaged tissue) on the sacrum (buttocks). This facility failure resulted in Resident 1's resident representative not being informed of their CoC or of the risks and benefits of the treatment options available to them. Findings: During a review of the facility's policy and procedure (P&P) titled, Change of Condition Reporting, dated 11/22, the P&P indicated, Purpose: To clearly define guidelines for timely notification of a change in resident condition . Licensed nurse will inform family of change of condition and document notification. During a review of Resident 1's Minimum Data Set ((MDS) an assessment tool for a resident), dated 11/23, the MDS indicated, Resident 1 had a Brief Interview for Mental Status BIMS of 6 (a system that measures mental status in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-22 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to implement its policy for activities when: 1. One of eighteen sampled residents (Resident 59) was not observed in any activities during onsite four-day survey. 2. The activity director was not documenting activity pursuit patterns or activity attendance for any of the 75 residents in the facility. This failure has the potential for psychosocial and physical harm to all 75 residents. Findings: During a review of the facility's policy and procedure (P&P) titled, Activity Assessment, dated 01/2021, the P&P indicated, POLICY: It is the policy of this facility to provide ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities based on the comprehensive assessment and care plan and the preferences of each resident. PROCEDURES: 4. A quarterly and annual assessment shall be conducted using the Activity - Quarterly or Annual Evaluation UDA (User Defined Assessment consists of questions compiled together under various headings…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-22 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure its medication error rate was less than five percent when: 1. Licensed Nurse 5 (LN 5) left medications intended for Resident 38 unattended on the medication cart. 2. LN 5 did not educate and provide Resident 38 water to rinse mouth out after inhalation of Ellipta powder medication. 3. LN 5 left Resident 38's medications unattended on bedside table and did not witness medication consumption. These failures resulted in a 10% medication error rate and had the potential for Resident 38 to have medication complications. Findings: Review of the facility's policy and procedures (P&P) titled, 6.0 General Dose Preparation and Medication Administration, revised 1/1/13, the P&P indicated in part, . Facility staff should not leave medications or chemicals unattended . Provide the resident with any necessary instructions (e.g., using an inhaler) . Observe the resident's consumption of the medications(s) . 1. During an observation and record review on 6/19/23, at 1:32 p.m., LN 5 entered Resident 38's room with back…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to store two boxes containing eggs inside of refrigerator and off the kitchen floor in accordance with professional standards of food safety for a total of 72 residents who received food from the kitchen. These failures had the potential to result in foodborne illnesses among residents. Findings: According to the Food Code 2022, Annex 3. Public Health Reasons/Administrative, 2-103.11, page 308 All food must be appropriately stored in a safe and secure manner within the food establishment. For example, time/temperature control for safety foods must be stored within refrigeration units and held at temperatures of 41°F or below. Also, 3-202.11 Temperature, page 376 indicated in part, USDA published a final rule (63 FR 45663, August 27, 1998 Shell Eggs; Refrigeration and Labeling Requirements) to require that shell eggs packed for consumer use be stored and transported at an ambient temperature not to exceed 7.2ºC (45ºF). Additionally, 6-501.12 Cleaning, Frequency and Restrictions, page 504 indicated, Primary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to develop, and implement a person-centered activity care plan for one of 18 sampled residents (Resident 59). This failure had the potential for isolation, psychosocial and physical decline for Resident 59. Findings: During a review of the facility policy and procedure (P&P) titled, Care and Treatment, Care Planning, revised 11/2021, the P&P indicated, POLICY: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive Person-Centered Care Plan for each resident based on resident's needs to attain or maintain his or her highest practicable physical, mental, and psychological well-being. PROCEDURES: 4. To the extent possible, the resident, the resident's family and/or responsible party should participate in the development of the care plan. During a review of the facility's P&P titled, Activity Assessment, revised 01/2021, the P&P indicated, POLICY: It is the policy of this facility to provide ongoing program to support residents in their choice of activities, both…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-22 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure physician orders were followed for one resident (Resident 38) when the resident did not rinse their mouth after receiving a medication via an inhaler. This failure had the potential to cause a fungal infection in Resident 38's mouth and throat. Findings: Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicated, Nurses are obligated to follow physician orders unless they believe the orders are in error or would harm clients. Review of the facility policy and procedure (P&P) titled, Medication Administration, revised 11/2021, the P&P indicated in part, Accurate and timely administration according to MD order is essential . According to Breo Ellipta product information accessed at https://www.mybreo.com/ on 6/27/23, BREO can cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth 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.
- Potential for harm · D2023-06-22 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 278) receiving the medication Apixaban (an anticoagulant or medication that prevents the blood from clotting) was monitored for complications and the monitoring documented in the resident's clinical record. This oversight failure had the potential to result in serious harm to Resident 278. Findings: During a review of Resident 278's, admission Record, dated 6/20/23, the record indicated in part, Resident 278 was an [AGE] year-old male admitted to the facility on [DATE], with admission diagnoses including, abscess (a collection of pus within the tissue) of the liver, unspecified atrial fibrillation (fluttering of the heart), and unspecified psychosis (a condition of the mind that results in difficulties determining what is real and what is not real) not due to a substance or known physiological condition. During a review of Resident 278's, Order Recap Report (ORR), dated 6/1/23 - 6/30/23, the ORR indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-22 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 278) was properly assessed for the continued use of the medication Quetiapine (brand name: Seroquel - a medication used to treat certain mental or mood conditions such as schizophrenia, bipolar disorder, and depression) as required by its policy and procedures on psychotropic (drugs that affect the brain and behavior) drug use. This failure resulted in Resident 278 receiving an unnecessary psychotropic medication which had the potential to result in serious complications from prolonged use without proper monitoring. Findings: During a review of the facility's policy and procedures (P&P) titled, Psychotropic Drug Use, dated 5/19, the P&P indicated in part, Procedures: 1) Psychotropic medications shall not be administered for the purpose of discipline or convenience. They are to be administered only when required to treat the resident's medical symptoms . 2) On admission, the admitting nurses will review the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-22 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure pharmacy services policy and procedure (P&P) for medication disposal was followed when medication pills were observed inside a trash receptacle. This failure had the potential for misuse of medications and jeopardize residents' health and safety. Findings: During an observation and subsequent interview on 6/19/23 at 4:51 p.m. with licensed nurse (LN 6) and the director of nursing (DON), a trash can at nursing station two-three was observed and contained a discarded medication card bubble pack with two unused tablets. Inside of each individual segmented plastic bubble was a single tablet of Amlodipine Besylate (medication to treat high blood pressure) Tab USP (United States Pharmacopeia - quality standards of the United States) 10 mg (milligrams). LN 6 confirmed and acknowledged being responsible for throwing the bubble pack containing two tablets of Amlodipine Besylate Tab USP 10 mg Tab into the trash can and not disposing the medications properly. LN 6 stated, I was disposing of the medications, and I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.2 | +1.8 vs chain |
| Health inspection | 5 of 5 | 2.8 | +2.2 vs chain |
| Staffing | 4 of 5 | 2.7 | +1.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| WILLITS, ADAM | Individual | CORPORATE DIRECTOR | since 01/15/2019 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | since 01/15/2019 |
| CULLIFER, JARED | Individual | CORPORATE OFFICER | since 01/01/2024 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | since 03/01/2011 |
| SATO, AMI | Individual | CORPORATE OFFICER | since 09/09/2024 |
| COOLEY, TIMOTHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2019 |
| GONZALES, ARLENE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/30/2019 |
| PORT, BARRY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 08/04/2025 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | since 01/15/2019 |
CMS files one row per role, so the 11 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055830. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-25, 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.