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Spring Lake Village

5555 Montgomery Drive, Santa Rosa, CA 95409 · Non profit - Corporation · 70 certified beds · (707) 538-8400 Medicare only — no Medicaid

Call the home — (707) 538-8400 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0609) — most recent Jan 2026
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (22% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4690 Hoen Ave · (707) 573-6942 · Call to confirm hours
Pharmacy
Hoen Ave, Santa Rosa, CA 95405 · (707) 528-4511 · Call to confirm hours
Grocery
Safeway0.9 mi
100 Calistoga Rd · (707) 539-1711 · Call to confirm hours
Park
5390 Montgomery Dr · (707) 539-8092 · Typically dawn to dusk
Place of worship
5680 Sonoma Hwy · (707) 539-4673

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.

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 increased15.4%10.2%15.4%typical
Long-stay residents who lose too much weight0.0%4.0%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
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 injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened26.8%9.8%16.1%worse
Long-stay residents on antianxiety or hypnotic medication3.8%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine91.7%98.2%95.3%typical
Long-stay residents with pressure ulcers2.6%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control31.0%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 table10.5%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.4%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine84.2%93.2%79.4%typical
Short-stay residents rehospitalized after admission19.2%23.0%22.6%better
Short-stay residents with an outpatient ER visit9.7%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days0.902.251.67better
Long-stay outpatient ER visits per 1,000 resident days0.401.571.80better

* 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.

64.2% 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 177 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

64.2%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
79.3%U.S. median 56.6%
Met the expected recovery
0.38U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 79.3% 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 116 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 SNF64.2%CMS range 57.7–69.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 5.9–13.610.7%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 discharge79.3%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 discharge69.0%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 discharge79.3%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 identified97.0%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 setting99.0%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.5%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 hospitalization6.2%CMS range 3.7–10.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 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

1.10
RN hours/ resident / day
1.32
LPN hours/ resident / day
3.12
Aide hours/ resident / day
5.54
Total nurse hours/ resident / day
0.81
RN hoursweekends
22.1%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 70 beds and averages 41.7 residents a day — about 60% occupied, or roughly 28 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.10 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.12 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.85 hrs/resident/day on weekends vs 5.82 on weekdays — 17% thinner on weekends. RN hours go from 1.22 to 0.81 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 22% 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

4
deficiencies at the latest standard inspection (2026-01-22)
15
at the previous standard inspection (2025-02-13)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · Ecited before2026-01-22 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record reviews, the facility failed to ensure, the enhanced barrier precautions (EBP, an infection control intervention, primarily used in nursing homes, that involve the use of gowns and gloves during high-contact resident care activities to reduce the transmission of infection) were implemented for two out of two residents sampled for infection control (Residents 29 and 45 ) that had opened wounds.This failure could result in increased transmission of germs and increased risk of infections among residents, staff, and visitors. Findings:A review of Resident 29's face sheet (FS, front page of the chart that contains a summary of basic information about the resident) indicated an admission date in 11/2025 with a diagnosis of Spinal stenosis (narrowing of the spinal canal that puts pressure on the spinal cord and nerves, causing pain, numbness, or weakness in the back, neck, or limbs) and trochanteric bursitis (painful swelling near hip joint).A review of Resident 29's progress note titled skin issues, dated 1/12 /26, indicated Resident 29 acquired…

    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 · D2026-01-22 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record reviews, the facility failed to ensure one out of two residents sampled for restraints (Resident 46) was free from physical restraints that were not required to treat the resident's medical symptoms when:1. No medical symptom identified that required the use of a pommel cushion (a specialized wheelchair or chair cushion with a raised section (pommel) between the legs; can be considered a restraint requiring careful assessment and physician orders for safe use);2. No physician order for the use of the pommel cushion; and3. No ongoing monitoring and evaluation for Resident 46's use of the pommel cushion.These failures could put Resident 46 at risk for movement restrictions and reduced functional independence.Findings:A review of Resident 46's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date in 7/2025 with a diagnosis of muscle weakness, unspecified abnormalities of gait (the way a person walks) and mobility (ability to move) with a need for assistance 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews, the facility failed to ensure two out of two residents sampled for grooming (Residents 29 and 16) received care to maintain grooming when their fingernails were long with brownish material underneath.This failure could negatively affect the residents' sense of dignity and be an infection control concern.Findings:A review of Resident 29's face sheet (FS, front page of the chart that contains a summary of basic information about the resident) indicated an admission date in 11/2025 with a diagnosis of Spinal stenosis (narrowing of the spinal canal that puts pressure on the spinal cord and nerves, causing pain, numbness, or weakness in the back, neck, or limbs) and trochanteric bursitis (painful swelling near hip joint).A review of Resident 29's care plan (CP, a detailed, written document that outlines a resident's individual needs, goals, and how their care will be managed) for focus .self care and mobility deficit., initiated on 12/01/25, indicated staff were to check nail length and trim and clean on bath day and as necessary.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 before2026-01-22 · 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

    Based on observation, interviews and record reviews, the facility failed to preserve skin integrity for one out of two residents (Resident 29) sampled for pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) when pressure ulcer preventative measures were not consistently implemented for Resident 29.This failure resulted in Resident 29 developing a stage 2 pressure ulcer (Partial-thickness loss of skin, presenting as a shallow open sore or wound) on her coccyx (tailbone) while at the facility.Findings:A review of Resident 29's face sheet (FS, front page of the chart that contains a summary of basic information about the resident) indicated an admission date in 11/2025 with a diagnosis of Spinal stenosis (narrowing of the spinal canal that puts pressure on the spinal cord and nerves, causing pain, numbness, or weakness in the back, neck, or limbs) and trochanteric bursitis (painful swelling near hip joint).A review of Resident 29's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-15 · 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

    Based on interviews and record reviews, the facility failed to implement their policy to immediately report an allegation of abuse, for one resident out of three sampled residents (Resident 1), when Resident 1 notified staff of an allegation of abuse on 4/13/25 but was not reported to California Department of Public Health (the Department) until 4/15/245. This failure had the potential to leave Resident 1 vulnerable to further harm or abuse, delay the investigation and corrective actions to address the allegation of abuse. Findings: On 4/15/25, the Department received a report from the facility which indicated Resident 1 accused Certified Nursing Assistant A (CNA A) of sexually abusing her. During an interview on 4/15/25, at 1:45 PM, the Administrator stated the incident was reported to him sometime around 4 PM on 4/14/25. During an interview on 4/15/25, at 3:10 PM, CNA A stated while he was taking care of Resident 1 with CNA C on 4/13/25, Resident 1 accused him of raping her. CNA A stated he reported the incident to Licensed Nurse B (LN B) but was not aware if LN B reported 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-02-13 · tag F0880 — failed to prevent and control infections — widespread
    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 1 b. During a review of Resident 14's face sheet (demographics), the face sheet indicated, Resident 14 was admitted to the facility on [DATE], with diagnoses which included sepsis (a life-threatening complication of an infection) and urinary tract infection (bladder infection). During a concurrent observation and interview on 2/9/25 at 4:06 p.m. with Resident 14, Resident 14 had an indwelling midline catheter (flexible tube inserted through the skin into a large vein in the arm used to administer IV antibiotics). There was no signage posted to alert staff that Resident 14 required Enhanced Barrier Precautions. Resident 14 stated that she was receiving Intravenous (IV) antibiotics (medicine that kills bacteria or stops their growth) for a urinary infection. During an observation on 2/10/25 at 4:10 p.m. in Resident 14's room, Infection Preventionist/Registered Nurse (IP/RN) administered IV antibiotics through Resident 14's midline catheter. IP/RN was not wearing a gown during the observation. During an observation…

    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 · F2025-02-13 · tag F0945 — failed to train staff on abuse prevention — widespread
    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to maintain an effective infection control training program related to Enhanced Barrier Precautions (EBP [Centers for Disease Control guidance to wear personal protective equipment when caring for residents with an indwelling medical device designed to reduce the spread of infections]). (cross reference to F880). This failure had the potential to negatively affect the facility's ability to maintain a safe environment to prevent the spread of infectious diseases among the 47 residents in the facility. Findings: During an interview on 2/12/25 at 2:13 p.m., with Infection Preventionist Registered Nurse (IP/RN) and the Director of Staff Development (DSD), the IP/RN and DSD stated they did not know what EBP was, therefore, they had not developed a policy and procedure or trained staff regarding EBP. During a review of the All Facilities Letter (AFL memo issued by the California Department of Public Health), dated 6/13/2024, indicated, skilled nursing facilities should implement EBP per Centers for Disease Control (CDC) guidance 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-13 · 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 safety and sanitation guidelines were followed when: 1. Two kitchen staff did not wear hair nets while in the kitchen. 2. Five of five green cutting boards were not in good repair. 3. Dented cans were not discarded. 4. Six boxes of dry goods were stored directly on the floor. 5. Multiple food items were expired. 6. Multiple food items were unlabeled and undated. 7. Sanitizer for the vegetable wash was expired. These failures posed the risk for food borne illness in a medically fragile resident population of 47. Findings: 1. During a concurrent observation and interview on 2/9/25 at 4:02 p.m. with Executive Chef (EC)in the Kitchen, the Server entered the kitchen and loaded a cart with food items, without a hair net. EC stated, No, she needs a hair net immediately. During a concurrent observation and interview on 2/10/25 at 10:13 a.m. with Certified Executive Chef (CEC)in the Kitchen, Dishwasher (DW) 2 was washing dishes, without a hair net. CEC stated, No, he needs a hair net. During a review of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · 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 two of 18 sampled residents (Resident 29 and 37) needs and preferences were met when: 1. Resident 29's call light was not within reach. This failure had the potential to result in Resident 29 being unable to get assistance as needed. 2. Resident 37 did not recieve assistance to get out of bed and dressed earlier in the morning. This failure had the potential to adversely impact Resident 37's quality of life. Findings: 1. During a review of Resident 29's face sheet (demographics), dated 2/10/25, the face sheet indicated Resident 29 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (a progressive and irreversible brain disorder that causes a gradual decline in memory, thinking skills and behaviors) and weakness. During an observation on 2/9/25 at 5:56 p.m., in Resident 29's room, Resident 29 was lying in bed with his square pad call light not within his reach. During an interview on 2/9/25 at 6:02…

    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 · D2025-02-13 · 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 provide a safe, clean, comfortable, and homelike environment when: 1. Personal use items including toothbrushes, toothpaste and combs were observed in a shared restroom for Residents 5, 8, 18, and 145 in a unlabeled wash basin (a pink colored wash basin/container for each resident used to store their personal use items). 2. Resident 18's personal use item was observed on Resident 145's (roommates) bedside table. These failures had the potential to cause illness and cross contamination in a medically compromised population. Findings: 1. During an observation on 2/9/25 at 3:19 p.m. and 3:45 p.m., in a shared restrooms for Resident 5, Resident 8, Resident 18 and Resident 145, personal use items were observed in a unlabeled wash basin. During an interview on 2/10/25 at 4:19 p.m., with Certified Nurse Assistant (CNA) 2, CNA 2 stated the room number should be on the wash basin that holds the resident personal use items, but not the name. 2. During an observation on 2/10/25 at 4:01 p.m., in room Resident 18's,…

    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
Show the remaining 16 citations
  • Potential for harm · D2025-02-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the plan of care for two of 18 sampled residents (Resident 29 and Resident 22) when: 1. Resident 29 did not have bedside fall safety mats. 2. Resident 22's heels were not elevated off the bed. These failures had the potential to result in subsequent falls with serious injuries and worsening of skin breakdown. Findings: 1. During a review of Resident 29's face sheet (demographics), dated 2/10/25, the face sheet indicated, Resident 29 was admitted to the facility on [DATE], with diagnoses to include of Alzheimer's disease (a progressive and irreversible brain disorder that causes a gradual decline in memory, thinking skills and behaviors) and weakness. During a review of Resident 29's Fall Care Plan, dated 11/18/24, the Fall Care Plan indicated, Resident 29 was at risk for falls and had six previous falls. Resident 29's Fall Care Plan indicated, the intervention for Resident 29 to avoid serious injury was to Place fall mats on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · 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 interview and record review, the facility failed to ensure weekly skin assessments were conducted and documented for one of 18 sampled residents (Resident 21) right heel pressure ulcer (PU- an injury to the skin caused by prolonged pressure on a specific area, often over bony prominences like the heels or tailbone). This failure had the potential to result in delayed treatment and servives required to promte wound healing. Findings: During a review of Resident 21's face sheet (demographics), the face sheet indicated Resident 21 was admitted to the facility on [DATE], with diagnoses to include Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors and difficulty walking). During an interview on 2/11/25 at 2:05 p.m., with Infection Preventionist/Registered Nurse (IP/RN), IP/RN stated nursing staff should conduct a head-to-toe skin assessment on every resident at least weekly. IP/RN further stated pressure ulcer/wound assessments should be conducted 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure shower disinfectant was stored in a locked storage container. This failure had the potential to result in unintentional access and harm. Findings: During an observation on 2/9/25 at 4:20 p.m., in Shower room [ROOM NUMBER], there was an unlocked storage container on top of a cupboard with signage stating, Keep locked at all times. The container contained a clear liquid and was labeled Shower disinfectant. During an interview on 2/9/25 at 4:24 p.m., with Restorative Nursing Aide (RNA) 1, RNA 1 stated the storage container should have been locked because the shower disinfectant was stored there. During an interview on 2/11/25 at 10:17 a.m., with the Director of Nursing (DON), the DON stated disinfectant should have been stored in a locked storage container. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces, 2025, the P&P indicated, .21. Chemicals used to clean 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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 effectively manage pain for one of 18 sampled residents (Resident 200). This failure resulted in unrelieved pain for Resident 200. Findings: During a review of Resident 200's face sheet (demographics), the face sheet indicated that Resident 200 was admitted to the facility on [DATE], with diagnoses to include disseminated malignant neoplasm (a cancer that has spread to multiple parts of the body). On 2/6/25, Resident 200 was admitted to hospice care (a type of medical care for those with an incurable illness with a life expectancy of six months or less) with comfort focused measures only (palliative care -specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). During a concurrent observation and interview on 2/10/25 at 10:23 a.m., with Resident 200's daughter, in Resident 200's room. Resident 200 was observed asleep in bed. Resident 200's daughter stated that Resident 200 was new 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 the medication error rate was not greater than five percent when five identified medication errors out of 41 opportunities for medication administration were observed: 1. Pradaxa (medication to treat irregular heart rate) was not administered with a full glass of water, as ordered, for one unsampled resident (Resident 14). 2. Furosemide (medication to treat high blood pressure) was given outside of dosing parameter instructions for one unsampled resident (Resident 14). 3. Aspirin (medication used to prevent stroke) was administered at the wrong time for one of 18 sampled residents (Resident 199). 4. Oxybutynin (medication used to treat overactive bladder) was administered at the wrong time for one of 18 sampled residents (Resident 199). 5. Potassium (medication used to treat low blood potassium electrolyte) was administered at the wrong time for one of 18 sampled residents (Resident 199). These failure resulted in an overall…

    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 before2025-02-13 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 the daily maximum dosage of acetaminophen (medication used to treat pain) did not exceed 2,000 milligrams (mg- unit of measurement) per physician's order for one unsampled resident (Resident 36). This failure had the potential to result in hepatotoxicity (damage to the liver caused by exposure to harmful substances). Findings: During a review of Resident 36's face sheet (demographics), dated [DATE], the face sheet indicated Resident 36 was admitted to the facility on [DATE], with diagnoses to include chronic hepatitis (long term inflammation of the liver). Resident 36 expired on [DATE]. During a concurrent interview and record review on [DATE] at 10:19 a.m., with the Director of Nursing (DON), Resident 36's Medication Administration Records (MAR) for the months of [DATE], [DATE], [DATE], and [DATE] were reviewed and indicated the following: a. In [DATE], Resident 36 had an order for acetaminophen 500 mg one tablet three times a day for pain,not…

    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 · D2025-02-13 · 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 store and label drugs and biologicals properly when: 1. Controlled drugs (drugs that are regulated by law due to their potential for abuse and addiction) were being discarded in a container that was not secure or permanently affixed to the wall. This failure had the potential to result in drug diversion (illegal distribution or abuse of prescription drugs.) 2. Resident 29's oxygen humidifier bottle was opened and undated. This failure had the potential to result in an increased risk for bacteria growth and progression of respiratory illness. Findings: 1. During a concurrent observation and interview on 2/11/25 at 2:25 p.m., with Registered Nurse (RN) 2 in the Medication Room, there was a Smart Sink (a green container with openings on the left and right side) sitting on the countertop. It contained a glass bottle, pills, and packaging. RN 2 stated that was where narcotic medications were disposed of when the Director of Nursing (DON) 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · tag F0802 — failed to prepare enough nourishing food — isolated
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure all kitchen staff were evaluated for competency skills when two kitchen staff were unable to effectively test the 3-compartment sink (3 sinks that separate the wash, rinse and sanitizer-manual procedure for cleaning and sanitizing dishes) sanitizer. This failure had the potential for residents to be served food on unclean dishes, which can result in food borne illnesses (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 47 residents. Findings: During a concurrent observation and interview on 2/9/25 between 3:50 to 3:55 p.m., with Executive Chef (EC) in the kitchen, EC tested the quaternary ammonium (quat- a group of chemicals that are used in disinfectants) in the 3-compartment sink. EC placed the strip in the mixture of quat sanitizer with water, for 10 seconds and the color of the strip changed to dark green. EC checked the color against the color chart on the test kit. EC confirmed the test strip read 600-800 ppm (parts per…

    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 · D2025-02-13 · tag F0813 — isolated
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    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 that all resident personal foods were labeled and dated in the communal refrigerator. This failure had the potential for residents to consume expired food that could lead to the increased risk of food borne illness (a sickness caused by consuming food contaminated with harmful substances). Findings: During an observation on 2/9/25 at 2:40 p.m., of the Residents' communal refrigerator located in the Hydration Room, there was a pizza box that contained pizza, and a package that contained crackers, cheese, and salami. The box and package were unlabeled with resident names, room numbers, and undated. During an interview on 2/9/25 at 5:22 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Oh no, they need the date with room number. During a review of the facility's policy and procedure (P&P) titled, Use and Storage of Food Brought to Residents From the Outside, dated January 2025, the P&P indicated, Food Storage: the outside food must be stored in an appropriate container, labeled with 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one of two outside dumpsters had a lid. This failure had the potential to attract pests and/or rodents that carried diseases and could result in food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 47 residents. Findings: During a concurrent observation and interview on 2/9/25 at 4:08 p.m., with the Executive Chef (EC) in the outside loading dock area, one compactor dumpster did not have a lid to cover the overflowing garbage that contained food and waste. The EC stated the dumpster should have a lid. During a review of the U.S [United States] Food and Drug Administration's (FDA) Food Code, dated 2022, the FDA Food Code indicated in Section 5-501.15 Outside Receptacles, (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers .…

    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 · Fcited before2023-04-07 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 the floors of the walk-in refrigerators and freezer were clean. This failure resulted in food storage areas that were not sanitary. Findings: During an observation and concurrent interview on 4/3/23 at 9:02 a.m., the floor of the Prep Fridge had an accumulation of food debris. On the floor under the bottom shelves were a whole onion, a pickle slice, a wrapped butter pat, and a bottle of lime juice. Management Staff D verified these items under the shelves and stated the floors of the walk-in refridgerators and freezer were supposed to be cleaned every night. When queried, Management Staff D stated it looked like it was probably not cleaned last night. Continuing the observation, the floors of the Protein Fridge and walk-in freezer also had accumulated food debris. Management Staff D stated the floors looked like they were not swept like [they] were supposed to. During an interview 4/6/23 at 9:03 a.m., Registered Dietitian (RD) stated the kitchen leadership did daily kitchen inspections and monthly…

    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 · Fcited before2023-04-07 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    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 properly store its kitchen waste when the facility's recyling dumpster was propped open and had lids that did not properly close, and the trash compactor was left open. This failure could lead to infestation with insects or rodents. Findings: During an observation of the trash area and concurrent interview on 4/5/23 at 10:33 a.m., the trash compactor door was open with trash visible inside. Management Staff D stated the door should not be open and closed it. One of the two recycling dumpsters had its lid propped open with a large Styrofoam block. Management Staff D verified it should not be propped open and removed the Styrofoam block. The dumpster's lids sagged and were too short to close the dumpster properly. Management Staff D verified the lids did not close properly and stated they were probably worn from years of being opened and closed. Review of the Food and Drug Administration (FDA) Food Code, last revised 2022, Chapter 5: Water, Plumbing and Waste, subsection 5-5 Refuse, Returnables, and Recyclables…

    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 · E2023-04-07 · tag F0657 — failed to keep the care plan current — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and revise the care plans of two of 13 sampled residents (Residents 31 and 37) at least quarterly and as needed in order to ensure the needs of Residents 31 and 37 were met. For Resident 31, after the facility assessed Resident 31 to be at risk for pressure injuries (skin injuries caused by prolonged and unrelieved pressure), the facility failed to review and revise the pressure injury care plan at least quarterly and after Resident 31 developed pressure injuries. For Resident 37, after the facility assessed Resident 37 to be at high risk for falling, the facility failed to review and revise the fall prevention care plans after each fall and add different interventions when the fall prevention interventions in the care plan proved ineffective in preventing Resident 37 from falling. These failures placed Resident 31 at risk for pressure injuries and Resident 37 at risk for falls. Findings: RESIDENT 31 A review of Resident 31's facesheet 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-07 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    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 an activities program that supported the choice of activities of four of 13 sampled residents (Residents 17, 19, 35 and 38) when the facility did not have sufficient activities staff to take these residents out for fresh air and outdoor activities. This failure resulted in Residents 17, 19, 35 and 38 being deprived of fresh air and outdoor activities which they reported were very important to them. Findings: During an observation and interview on 4/3/23, at 9:50 a.m., Resident 19 was alert and oriented and stated she was bored and idle at the facility. Resident 19 stated: We sleep a lot because there is nothing do. Resident 19 stated she enjoyed being out for fresh air and enjoyed outdoor activities but stated such activities were not offered by the facility. Resident 19 stated she only left the facility for fresh air or outdoor activities if family took her. Resident 19 stated when she asked staff to take her out for fresh air…

    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 · D2023-04-07 · 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 observation, interview, and record review, the facility staff failed to assess and document a large bruise on one of 13 sampled residents, Resident 12. This failure could potentially result in an unrecognized safety issue for the resident when the cause of the bruise was unknown. Findings: During an observation and concurrent interview on 4/3/23 at 11:38 a.m., Resident 12 had a dark purple bruise on her right forearm that was approximately 2.5 inches by 4 inches. Resident 12 stated she got the bruise when Unlicensed Staff A was helping her to the bathroom. When asked if the bruised area was painful, Resident 12 stated, This arm always hurts, but yes. During a record review on 4/4/23 at 11 a.m., Resident 12's electronic medical record indicated she was admitted to the facility on [DATE] with medical diagnoses that included respiratory failure, bacterial pneumonia (lung infection), sepsis (blood infection), and difficulty in walking, among others. Resident 12's MDS (minimum data set, an assessment tool)…

    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 before2023-04-07 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 administer one medication to one Resident (Resident 26) per MD orders. This failure had the potential to cause Resident 26 to have dizziness, lightheadedness, drowsiness, and or a runny/stuffy nose. Findings: During a medication pass observation on 4/6/23 at 5:27 p.m., Licensed Nurse B popped two tablets of Tamsulosin HCL Capsule 0.4mg (milligram) (medicine to treat Benign prostatic hyperplasia (BPH) causes male prostate to increase in size, causing feeling need to urinate ) into a medicine cup and added applesauce. Licensed Nurse B stated there were two tablets. Licensed Nurse B administer two tablets to Resident 26. During a reconciliation of medication pass by reviewing MD orders on 4/7/26 at 9:00 a.m. MD order for Tamsulosin HCL Capsule 0.4mg dated 4/19/22 indicated to give one capsule by mouth two times a day related to Benign Prostatic Hyperplasia (with lower urinary tract symptoms). During a review of Resident 26 medical record, Medication Administration Record on 4/7/26 at 9:08 a.m., Licensed Nurse B…

    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

“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 FRONT PORCH — 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 54.8+0.2 vs chain
Health inspection 4 of 54.2-0.2 vs chain
Staffing 5 of 54.9≈ chain avg
Quality measures 5 of 54.8+0.2 vs chain
The other 8 homes this chain runs (chain average 4.8★, 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
FRONT PORCH COMMUNITIES AND SERVICESOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 04/01/2022
DURANTEAU, NANCYIndividualCORPORATE DIRECTORsince 04/01/2021
FORTE, VINCENTIndividualCORPORATE DIRECTORsince 04/01/2021
HANDY, JOANNEIndividualCORPORATE DIRECTORsince 04/01/2021
JACOBS, LAURAIndividualCORPORATE DIRECTORsince 01/01/2019
KROEKER, KEVINIndividualCORPORATE DIRECTORsince 01/01/2018
MCGOVERN, MARIONIndividualCORPORATE DIRECTORsince 01/01/2017
SALVADOR, EDUARDOIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
SPENCER, PETERIndividualCORPORATE DIRECTORsince 01/01/2026
TONNU, DIEMLANIndividualCORPORATE DIRECTORsince 01/01/2018
WESSON, OLIVERIndividualCORPORATE DIRECTORsince 01/01/2017
WHITTAKER, SUSANIndividualCORPORATE DIRECTORsince 01/23/2018
KELLY, SEANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 03/06/2023
VRANICH, RACHELIndividualCORPORATE OFFICERsince 06/17/2022
AKOPYAN, GEVORKIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/12/2022
BOUT, FERDINANDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/29/2025
ICHIEN, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/04/2018
JUMAWAN, KRISTYLIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/20/2026
MACANGO, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/04/2026
MCMULLIN, MARYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2025
OLSON, KARIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2021
SKILLMAN, DANIELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/05/2021
ZELK, MISTYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2026

CMS files one row per role, so the 28 rows in the source record cover these 23 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.

$7.3M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
$393K
Related-party expense1% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 8%Other / private 92%

This home reported $393K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$1,565per resident / day
operating cost
$47,586per month
≈ monthly operating cost
$266per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the California Medicaid page for homes that do.

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 555268. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-22, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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