Apple Valley Post-Acute Rehab
1035 Gravenstein Hwy South, Sebastopol, CA 95472 · For profit - Corporation · 95 certified beds · (707) 823-7675 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (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 | 4 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 | 3.9% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.1% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.1% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.2% | 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 | 4.3% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 5.3% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 5.5% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.2% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.9% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.9% | 10.2% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.9% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 94.2% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.2% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.4% | 11.2% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.91 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.41 | 1.57 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
70.3% 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 289 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 73.0% 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 152 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 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 44% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 70.3%CMS range 65.6–75.4 | 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 | 9.0%CMS range 6.7–12.1 | 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 | 73.0% | 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 | 67.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.2% | 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 | 98.6% | 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 | 94.9% | 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 | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.6%CMS range 3.9–10.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.85 | 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 95 beds and averages 83.0 residents a day — about 87% occupied, or roughly 12 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 4.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.548 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.62 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 4.09 hrs/resident/day on weekends vs 4.72 on weekdays — 13% thinner on weekends. RN hours go from 0.58 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% 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 12 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2022-11-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 quality healthcare services for one of 18 sampled residents (Resident 76), when facility staff did not: 1. Utilize an accurate medication administration record (MAR, a clinical record indicating medications used by an individual, including the medication names, dosages, and administration times) that reflected the resident's current opioid regimen. Resident 76 received opioid medication orally and by intrathecal pump (e.g., continuous delivery of medication directly into the spinal cord) for pain management. 2. Administer the opioid-reversal agent Narcan, as ordered, when the resident appeared pale and sleepy on [DATE]. 3. Provide coordinated, safe physician services for pain management involving more than one physician-prescriber. These failures resulted in Resident 76 receiving higher, more frequent doses of opioid medication than expected by Physicians H and A, and a higher dose of intrathecal opioid medication than indicated by the MAR, 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.
- Actual harm · G2022-11-18 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 sufficient licensed nurses competent to manage one resident's (Resident 76) opioid-overdoses and intrathecal (e.g., continuous delivery of medication directly into the spinal cord via a pump system) opioid-delivery system, and manage another resident's (Resident 78) chest pain, when the facility's licensed nurses: 1. Could not consistently demonstrate the process for accessing and administering the opioid-reversal agent Narcan; 2. Were not trained how to safely care for residents using an intrathecal pump to deliver medication for pain management; 3. Did not appropriately respond to Resident 78's complaints of chest pain. Resident 76 required use of oral opioid medication as well as opioid medication administered via an intrathecal pump. Twice, on 8/26/22 and 9/2/22, Resident 76 was found unconscious and transferred to an acute care hospital for emergency services. On 9/2/22, Resident 76 was pronounced dead at the hospital,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-18 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 interviews and record reviews, the facility failed to ensure a dignified existence and the right to receive services promptly for one of three sampled residents (Resident 1), when staff did not respond in a timely manner to Resident 1's repeated calls for assistance while experiencing a life-threatening medical emergency.This failure delayed access to emergency care and made Resident 1 feel frightened and ignored, and had the potential to result in severe harm including death. A review of Resident 1's admission record (facility demographic) indicated she was admitted to the facility on [DATE] with diagnoses of left ankle fracture, diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor healing), and congestive heart failure (a disorder which causes the heart to not pump efficiently). This document also indicated Resident 1 was her own representative.A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 6/09/26 indicated it was incomplete 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 · Dcited before2025-09-09 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 interview and record review, the facility failed to report an allegation of abuse within the mandated timeframe for one resident (Resident 2) of two sampled residents when the facility submitted notification to the California Department of Public Health (CDPH) on 8/25/25 when the allegation of abuse was reported to a nurse on 8/24/25.This failure decreased the facility's potential to protect residents.Findings:A review of Resident 2's admission record indicated admission to the facility on 7/17/25 with diagnoses which included dementia (a progressive state of decline in mental abilities), mild cognitive impairment of unknown cause, and a need for assistance with personal care.A review of Resident 2's Minimum Data Set (an assessment tool) dated 7/20/25 indicated a Brief Interview for Mental Status (BIMS, a screening tool used to monitor cognitive function (the mental processes our brain uses to perceive, learn, remember, and reason)) score of 11 which indicated moderate cognition.A review of Resident 2's progress note dated 8/24/25 at 5:25 p.m. indicated, Resident's daughter…
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 · D2025-04-23 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to honor a resident's desire to go outdoors when one of two sampled residents, Resident 1, was asked repeatedly by multiple staff members to go inside to his room where he was in isolation for COVID-19. This failure potentially resulted in an escalation of Resident 1's anxiety prompting a call to the police and Resident 1's subsequent arrest. Finding: On 3/25/25, the Department received a report from the facility that on 3/24/25 at approximately 11:30 a.m., [Resident 1] became agitated in his covid isolation room. He exited the room using his walker without shoes or a mask on and went to exit the facility, to get fresh air and sun. As he approached the exit of the facility, the [facility] receptionist let him know he was not wearing the proper PPE (personal protective equipment) and was supposed to stay in his isolation room. Once inside, Resident 1 became significantly more agitated, 911 was called, police arrived, and after he became physical with one of the police officer, Resident 1 was arrested and escorted to the county…
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 · D2024-11-08 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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, interview, and facility policy review, the facility failed to issue a written notice of bed hold when a resident transferred to a local hospital for 1 (Resident # 78) of 2 sampled residents reviewed for hospitalization. This failure resulted in a bed not being available upon discharge of the resident from the acute care hospital. Findings included: Review of a facility policy titled; Bed Hold Acknowledgement/Notification, revised 03/29/2018, indicated 1. facility will issue two notices related to bed-hold: a The first notice will be given upon admission to the facility. Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility's policy were changed; b Second notice will be given at the time of transfer of a resident for hospitalization or therapeutic leave which specifies the duration of the bed-hold policy. An admission Record indicated the facility admitted Resident #78 on 09/19/2024. According to the admission Record, the resident had…
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 · D2024-11-08 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and facility policy review, the facility failed to resubmit a Level I screening for 1 (Resident #6) of 4 sampled residents reviewed for preadmission screening and resident review (PASARR, a tool to ensure residents are not inappropriately placed in nursing homes for long term care). This failure had the potential to affect the care the resident received. Findings included: An undated facility policy titled, Preadmission Screening and Resident Review, indicated 1. The facility will obtain/complete a Preadmission Screening and Resident Review timely. An admission Record indicated the facility admitted Resident #6 on 11/04/2019. According to the admission Record, the resident had a medical history that included diagnoses of adjustment disorder (an excessive reaction to stress), bipolar disorder (disorder characterized by mood swings between depressive lows and manic highs), and dementia. An quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/09/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-08 · 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, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene when soiled gloves were removed and before a new pair of gloves were put on during the provision of wound care for 1 (Resident #4) 1 sampled resident reviewed for pressure ulcer/injury. This failure had the potential to cause the spread of infection between residents. Findings included: A facility policy titled, Handwashing/Hand Hygiene revised 08/2019, revealed This facility considers hand hygiene the primary means to prevent the spread of infections. The policy specified, 6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handing an invasive device; f. Before donning (putting on) sterile gloves; g. Before handing clean or soiled dressings, gauze pads, etc.; h…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-02 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 that one of two sampled residents, Resident 1, received an accurate reconciliation of medications (A process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that included the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care) during her discharge, when Resident 1 received three (3) over the counter medications that were ordered for another resident, Resident 2. This failure had the potential to result in a medication error and could affect the safety and well-being of Resident 1, if she accidentally took the medications that were not ordered for her. Findings: On 7/2/2024, at 1:51 p.m., the facility's DON (Director of Nursing) provided a list of residents who were discharged in June 2024. The list included Resident 1, who was discharged on 6/7/24. During a concurrent observation and interview 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.
- Potential for harm · Dcited before2024-04-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to keep one of three sampled residents (Resident 1) safe from elopement (Leaving the facility without notice), when he had a history of attempting to elope from the facility and was able to walk without a wheelchair. The facility's intervention to prevent him from elopement included a wander guard (Bracelets that trigger alarms at exit monitored doors to prevent the resident from leaving unattended) placed on his wheelchair. As a result, Resident 1 eloped from the facility by foot, left the wheelchair at the facility, which did not trigger the wander guard system, fell during the process, and hitchhiked to a neighboring town 8.5 miles away. This failure had the potential to result in serious harm, including death, to Resident 1. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Nontraumatic Intracerebral Hemorrhage (Bleeding in the brain, not caused by trauma), Alcohol Abuse, Metabolic…
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 · E2023-12-12 · tag F0697 — failed to manage pain — patternProvide 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 manage two of three resident's (Resident 1 and Resident 2) pain according to professional standards of practice and resident's preferences when residents were not properly educated about their pain medication management. This failure resulted in increased pain levels and had the potential to cause a delay in recovery, impair mobility, impair mood, disturb sleep, and diminish quality of life and wellbeing. Findings: During an interview on 10/31/23, at 3:03 p.m., Resident 1 stated she had pain on the lower back, neck, and her whole body. Resident 1 stated her scheduled pain medication was not given on time. The longest she had to wait was half hour, depending on the nurse on duty. Resident 1 stated she did not like to wait because it messed up her schedule and made her pain worse. Resident 1 stated, about two weeks ago, a night shift nurse refused to give her pain medication, because the previous nurse supposedly already gave her 11 p.m.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to provide safety reminders, guidance, and assistance to one of four residents (Resident 1) before he tripped on a transition strip on the floor and fell while walking at the lobby of the facility. This failure resulted in Resident 1 sustaining a closed or incomplete fracture of the neck of the right thigh bone, pain, and hospitalization. Findings: A review of records indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of asthma, cognitive (natural skills including attention, memory, processing speed, reasoning, planning, problem solving, and multitasking) communication deficit, anxiety disorder, and major depressive disorder, among other conditions. Resident 1 ' s Minimum data set (MDS – federally mandated process for clinical assessment of each resident in Medicare and Medicaid certified nursing homes of their functional capabilities and help nursing home staff identify health problems) dated 6/3/23, indicated he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · F2022-11-18 · tag F0919 — failed to provide a working call system — widespreadMake sure that a working call system is available in each resident's bathroom and bathing area.
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 bathrooms used by residents in 34 of 34 resident rooms had a call light system accessible to residents lying on the floor. This failure placed all the 74 facility residents at risk of being unable to alert staff via the facility's communication system if they fell in the bathroom and were unable to get up. One of 18 sampled residents fell twice in the bathroom in 2022 and had to verbally call for staff assistance (cross-reference to tag F-689). Findings: During observations and interviews on 11/16/22, starting at 8:30 a.m., with the Director of Maintenance (DM), the call light system installed in the bathrooms used by residents in 34 of 34 rooms (room numbers 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36) consisted of a button placed on the wall next to the toilet seat at elbow height (while seated on the toilet) and within reach of a person…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-11-18 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure a comfortable environment for eight of 74 residents (Residents 19, 23, 31, 43, 47, 55, 60 and 182) when the ambient temperature at the facility was too cold for these residents. This failure resulted in Residents 19, 23, 31, 43, 47, 55, 60 and 182 reporting feeling cold and uncomfortable in their rooms. Findings: During an interview on 11/14/22, at 10:34 a.m., Resident 60 stated the temperature in his room was uncomfortably cold. During an interview on 11/14/22, at 10:36 a.m., Resident 182 stated the temperature in his room had been uncomfortably cold for the past two or three days. Resident 182 reported it was freezing in his room. During an interview on 11/15/22, at 9:30 a.m., Resident 55 stated the temperature in her room was uncomfortably cold. Resident 55 stated her room felt like an icebox. During observations on 11/16/22, starting at 8:30 a.m., with the Director of Maintenance (DM), the DM measured the ambient temperature of 32 of 34 resident rooms (room numbers 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,…
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 before2022-11-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 minimize accident hazards for three of 24 sampled residents (Residents 41, 279, and 2), when facility staff did not: 1. For Resident 41, accurately indicate the resident's fall history, past medical history, and medication history when assessing the resident's risk of falling. 2. For Resident 279, plan the resident's bowel and blader care to include interventions to mitigate falls associated with the resident's toileting pattern. 3. For Resident 2, implement fall prevention interventions to mitigate the resident's fall risk. The failure associated with Resident 41 resulted in the facility not collecting sufficient data to plan for the resident's fall risk and safety, and had the potential to not prevent future falls. The failure associated with Resident 279 contributed to the resident's fall 1/10/22 that caused a right ankle fracture. The failures associated with Resident 2 resulted in the resident experiencing two falls on 2/17/22 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 · E2022-11-18 · tag F0711 — patternEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to keep record of visits from the attending physician for one of three sampled residents, Resident 76. This failure resulted in Resident 76's caregivers and practitioners having no written record of his physician's examination, plan of care, or clinical decision-making for a six-month period of time. Findings: During a record review on 11/8/22 at 1:30 p.m., Resident 76's facesheet revealed an admit date of 2/18/22 and discharge date of 9/2/22. Review of Resident 76's paper and electronic medical records revealed there were no progress notes written by Resident 76's attending physician after 2/24/22. During a record review and concurrent interview on 11/8/22 at 2:55 p.m., Director of Nursing (DON) reviewed Resident 76's paper and electronic medical records with medical records staff and verified Resident 76's attending physician had not entered any progress notes since 2/24/22. DON stated the residents' physicians should write a progress note every 45 to 60 days. During an interview on 11/9/22 at 10:55 a.m., Physician A stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-11-18 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 sufficient staff to maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 18 sampled residents (Residents 44, 66, and 8), when nursing staff did not: 1. Timely respond to residents who triggered a call light 2. Follow the Facility Assessment's recommendation for nurse staffing. The call-light-response failure resulted in nurses taking between 12 and 38 minutes to respond to call lights, and caused Residents 44 and 66 to feel humiliated, as well as angry, helpless, and frustrated due to being left wet for an extended time. The failure to follow the Facility Assessment's staffing recommendation resulted in Resident 8 feeling bothered due to having untrimmed, long, dirty fingernails, and it did not allow the facility to meet the recommended total of nursing staff on multiple days. Findings: 1. A review of Resident 44's face sheet (demographics) indicated she was [AGE] years old, admitted to 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 · D2022-11-18 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 dignity and respect for one resident (Resident 8), when the resident regularly requested his fingernails be neatly trimmed but facility staff did not schedule time to provide the requested service. This failure resulted in Resident 8's fingernails growing long, sharp, and dirty, which caused Resident 8 to feel bothered by the long nails and caused accidental injuries to the resident's skin, and had the potential to cause an infection. Findings: A review of Resident 8's face sheet indicated he was [AGE] years old, admitted to the facility on [DATE] with the diagnoses of Hemiplegia (a symptom that involves one-sided paralysis) Hemiparesis (a weakness or the inability to move on one side of the body), Diabetes Mellitus (DM--a condition that happens when the body cannot use blood sugar normally) and Gout (an inflammatory disease affecting joints that is painful). A review of Resident 8's Minimum Data Set assessment (MDS--an assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-18 · tag F0573 — isolatedLet each resident or the resident's legal representative access or purchase copies of all the resident's records.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to follow its policy and procedure on disclosure and release of information, when a request for records of one resident (Resident 1) by her legal representative on 9/6/22, was not processed and released within two days. This failure did not ensure resident rights and had the potential to adversely affect Resident 1's health, safety, and best interests. Findings: During a review of Resident 1's admission Record, dated 9/23/22, the admission record indicated Resident 1 had Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). During a review of Resident 1's completed Physician Orders for Life Sustaining Treatment, (POLST) form, dated 6/27/22, at 2:20 p.m., the POLST form indicated, Resident 1's son was designated as her legally recognized decision-maker. During a concurrent record review and interview on 9/23/22, at 11:30 a.m., with Management Staff K, she stated she receives request for records via…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1) Ensure of one of one resident (Resident 280) was protected from potential abuse, when it discharged Resident 280 home with the suspected abuser on 10/22/22 without notifying Adult Protective Services (APS, a state-funded program that promote safety, independence, and quality-of-life of vulnerable adults). 2) Report the result of its abuse investigation for two of two residents (Residents 280 and 38) to the State Survey Agency (SSA), within 5 working days of the incident. These failures did not ensure residents' right to be protected from abuse, and did not comply with facility policy and procedure. Findings: 1) During a review of Resident 280's face sheet (demographics), it indicated she was [AGE] years old and was admitted to the facility on [DATE]. Her diagnoses included Parkinson's Disease (PD-a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-18 · tag F0679 — failed to provide activities — isolatedProvide 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 meet the activities' interests of one of 18 sampled residents (Resident 183) when Resident 183 enjoyed watching TV but was provided the remote control of another resident's TV. This failure did not support the well-being of Resident 183, which required the resident to watch TV looking sideways and caused the resident discomfort and neck pain. Findings: A review of Resident 183's facesheet indicated Resident 183 was admitted to the facility on [DATE] with diagnoses including depression and muscle weakness. During an observation on 11/14/22, at 10:10 a.m., Resident 183 was in his room. The room had two beds: one close to the door (Bed A) and one close to the window (Bed B). Each bed had a TV located in front of the bed. Resident 183 was lying in Bed A, but his head was turned to the left, and he was watching the TV placed in front Bed B. The TV placed in front of Resident 183's bed was turned off. During a concurrent interview, Resident 183…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-18 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to follow its policy and procedure in safe storage of food in the dry storage area when one expired item (seasoning sauce) was stored with other food items. The dietary staff wrote on the seasoning sauce container that it was opened on 10/26/21, and a used by date of 10/26/2022. The sauce container had a manufacturer's recommendation indicating it was best to use date by 7/31/2022. This failure had the potential to result in food borne illnesses to the residents of the facility. Findings: During a concurrent observation and interview on 11/16/22, at 9:55 a.m., with the Dietary Manager, at the kitchen's dry storage area, it was observed that a special sauce container with its content, was on the pantry along with other food items. The container had a hand-written date indicating it was opened on 10/26/21, and the use by date written was 10/26/22. Stamped on the sauce container was a manufacturer's recommendation that it was best to use by 7/31/22. A picture of the sauce container, along with the dates written on the container,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff demonstrated the appropriate use of PPE, when one direct care staff demonstrated inappropriate PPE re-use and santizing practices. These failure did not minimize the risk of spreading infection in the facility and did not comply with facility policy and procedure. Findings: During an interview on 11/17/22 at 1:38 p.m., the IP verified Human metapneumovirus (hMPV) is a common respiratory virus that causes an upper respiratory infection (like a cold or flu). She stated residents with hMPV should be placed on contact and droplet precautions (transmission-based precautions used when caring for patients whose illness may trasmit to other humans in contact with surfaces in a resident's room or when in close proximity to the resident) to prevent spread of infection. During a concurrent observation and interview in room [ROOM NUMBER] on 11/17/22, at 3:00 p.m., Certified Nursing Assistant (CNA) R was observed wearing two masks--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 · D2019-07-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility policy, the facility failed to ensure one resident, (Resident (R)19), of three sampled residents whose clinical records were reviewed for participation in care planning, were invited to their care plan meetings. Eighty-one residents resided in the facility. Findings include: Review of the Medical Diagnoses and Minimum Data Set (MDS) sections of R19's electronic health record (EHR) revealed the facility originally admitted the resident on 11/27/18, with a recent readmission on [DATE]. R19's diagnoses included atherosclerotic heart disease, epilepsy, heart failure, hypothyroidism, acute kidney failure, and diabetes mellitus. Review of R19's significant change in status MDS, with an Assessment Reference Date of 04/27/19, documented the resident had a Brief Interview for Mental Status score of eight out of 15, which indicated she had moderate cognitive impairment. The resident required supervision with eating, and required extensive assistance with most other…
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 NAHS — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.0 | +1.0 vs chain |
| Health inspection | 4 of 5 | 3.2 | +0.8 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.8 | +0.2 vs chain |
The other 11 homes this chain runs (chain average 4.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NAHS NORTH INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/30/2018 |
| NAHS HOLDING INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 06/30/2018 |
| LANE, JOANNE | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | — | since 02/01/2023 |
| MARSHALL, BRENT | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/18/2024 |
| BAJA, RALPH | Individual | CORPORATE DIRECTOR | — | since 07/01/2023 |
| BARLOW, JAMES | Individual | CORPORATE DIRECTOR | — | since 06/29/2018 |
| MOORE, MICHAEL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 02/01/2022 |
| PAULSEN, TIMOTHY | Individual | CORPORATE DIRECTOR | — | since 06/29/2018 |
| WALTON, MARK | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 06/29/2018 |
| JOHNSON, MARC | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 11/20/2022 |
| LUNDQUIST, VICTOR | Individual | CORPORATE OFFICER | — | since 03/21/2018 |
| SERRANO, NOEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2016 |
CMS files one row per role, so the 21 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $876K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055919. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-08, 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 →
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