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Torrance Memorial Med Ctr SNF/DP

3330 West Lomita Blvd, Torrance, CA 90505 · Non profit - Other · 40 certified beds · (310) 784-4924 Medicare & Medicaid certified

Call the home — (310) 784-4924 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (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
  • a high number of inspection citations overall (28) — 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 5 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
23600 Telo Ave Ste 260 · (310) 539-2055 · Call to confirm hours
Pharmacy
23600 Telo Ave Ste 155 · (424) 250-1701 · Call to confirm hours
Grocery
23777 Madison St
Park
2850 W 232nd St · (310) 618-2720 · Typically dawn to dusk
Place of worship

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
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 improved from 4 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Short-stay residents who newly got an antipsychotic medication0.6%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine96.3%93.2%79.4%better
Short-stay residents rehospitalized after admission21.4%23.0%22.6%typical
Short-stay residents with an outpatient ER visit1.3%11.2%12.0%better

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

68.7% 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 527 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

68.7%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
39.5%U.S. median 56.6%
Met the expected recovery
0.84U.S. median 0.31
Therapy hours / resident / day
<0.01hours / resident / day
Physical therapy
0.80hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 39.5% 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 185 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 0.84 therapist hours per resident per day in 2026Q1 — more than 95% 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 SNF68.7%CMS range 64.5–72.151.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 8.6–13.310.7%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 discharge39.5%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 discharge29.7%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 discharge25.9%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 identified99.0%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 setting100.0%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 discharge97.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened1.7%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 hospitalization5.2%CMS range 3.0–7.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.771.02Oct 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

5.14
RN hours/ resident / day
0.12
LPN hours/ resident / day
3.20
Aide hours/ resident / day
8.46
Total nurse hours/ resident / day
4.59
RN hoursweekends
21.9%
Total nursing turnover
18.4%
RN turnover

How full it usually is: this home is certified for 40 beds and averages 31.6 residents a day — about 79% occupied, or roughly 8 beds typically open. It usually has some room. 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 8.46 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 5.14 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.20 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 7.90 hrs/resident/day on weekends vs 8.69 on weekdays — 9% thinner on weekends. RN hours go from 5.37 to 4.59 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

3
deficiencies at the latest standard inspection (2026-03-15)
6
at the previous standard inspection (2025-01-19)

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.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Dcited before2026-03-15 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the physician of a change of condition for one of one sampled residents (Resident 35) when Resident 35's oxygen saturation ([O2 sat]- a measurement of how much oxygen the blood is carrying as a percentage) decreased to 90 percent ([%] a number or ratio expressed as a fraction of 100) on room air (normal O2 sat is 92% -100%).This failure resulted in Resident 35 experiencing respiratory distress, agitation and being transferred to the General Acute Care Unit (GACH) for evaluation and treatment.Findings:During a review of Resident 35's admission record, the admission record indicated Resident 35 was admitted to the facility on [DATE] with diagnosis including a left femoral (thigh bone) open reduction and internal fixation (ORIF-surgery used to stabilize and heal a broken bone) that required rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being), stroke (loss 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-15 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure 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 interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 was competent in providing one to one care ([1:1 sitter] provides constant supervision to a single patient to ensure safety) for one of one residents (Resident 38) who was diagnosed with suicidal ideations (death caused by injuring oneself with the intent to die) in the facility.This deficient practice had the potential to affect Resident 38 and all residents requiring close observation, and placed them at risk for self-harm, hospitalization and death.Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE].During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool) dated 3/13/2026, the MDS indicated Resident 38's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 38 was dependent (helper does all the effort) with activities of daily living (ADLs-…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices by failing to:Ensure staff change gloves after picking up a dirty trashcan and before passing medications to one of three sampled residents (Resident 4).Ensure visitors followed Enhanced Barrier Precautions (EBP- infection control steps requiring staff to wear gowns and gloves during high-contact care [dressing, bathing, or changing linen] for residents with, or at risk of, germ-resistant infections) for one of three sampled residents (Resident 40).These failures had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place all residents at risk for spread of infection.Findings:1. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility 2/3/2026.During a review of Resident 4's History and Physical (H&P) dated 2/4/2026, the H&P…

    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 before2025-01-19 · 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: a. opened, unlabeled and undated bag of pepperonis with freezer burns was not stored in the freezer and was discarded. b. the temperature on a High Temperature Dishwasher wash cycle was 150 degrees Fahrenheit. These failures had the potential to result in residents eating compromised quality of meat due to dryness and altered texture and had the potential to result in residents being exposed to rapid growth of bacteria that can cause foodborne illness (food poisoning). Findings: During a concurrent observation and interview on 1/17/2025 at 5:00 pm, with Manager of Patient Services (MOPS) in the kitchen, Freezer #14 had an unlabeled open bag of pepperonis with freezer burns. During an interview on 1/19/2025 at 10:55 pm with Dishwasher (DW ) 1, DW 1 stated when washing dishes the temperature is 150 degrees Fahrenheit. DW 1 stated it is important to wash dishes at 150 degrees Fahrenheit to kill the bacteria. During an observation on 1/19/2025 at 11:37 am in the kitchen, the temperature on the dishwasher…

    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 before2025-01-19 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to notify the physician on one of four sampled residents (Resident 122) by: 1. Failing to notify the physician and document a change in condition when Resident 122 had an episode of nausea and vomiting and refusal to eat. This failure had the potential to delay treatment or care for Resident 122. Findings: During a review of Resident 122's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility. During a review of Resident 122's History and Physical (H & P) dated 1/7/2025, the H & P indicated the resident was admitted with diagnoses that included history of breast cancer ( a disease when an abnormal breast cells grow out of control and form tumors in the breast which was treated in the past), metastatic disease to the bone (cancer that had spread to the bone), atrial fibrillation( heart condition that causes an irregular heart beat), stage 3 pressure ulcer ( full thickness loss of skin and dead 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-19 · 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 failed to provide services which meet professional standards of quality for one of four sampled residents (Resident 12) by failing: 1. To ensure vital signs (measurements of the body's most basic functions such as heart rate, breathing rate, blood pressure, and temperature) were obtained before administering medications that can affect blood pressure( bp- force of blood pushing against the walls of the arteries). 2. To ensure vital signs reading taken two hours ago before administration of an anti-hypertensive medicines (medicines that are used to lower high blood pressure) was not used as a parameter(limit that affects how something is done) to administer the medicine. These failures have the potential to put Resident 12 at risk for hypotension (low blood pressure) that could lead to fall. Findings: During a review of Resident 12's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-19 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 2) was free from receiving an unnecessary antibiotic, to treat a skin tear (a wound that occurs when the skin separates due to friction, blunt force, or shear). This failure had the potential for Resident 2 to experience adverse side effects, antibiotic resistance and to receive an inappropriate antibiotic. Findings: During a review of Resident 2's Registration Record, the Registration Record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2's History and Physical (H&P), dated 12/17/2024, the H&P indicated Resident 2 had diagnoses of but not limited to a skin tear of the lower leg without complication, pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) with left lower leg weakness. During a review of Resident 2'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-19 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 2) was free from receiving an unnecessary antibiotic, to treat a skin tear (a wound that occurs when the skin separates due to friction, blunt force, or shear). This failure had the potential for Resident 2 to experience adverse side effects, antibiotic resistance and to receive an inappropriate antibiotic. Findings: During a review of Resident 2's Registration Record, the Registration Record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2's History and Physical (H&P), dated 12/17/2024, the H&P indicated Resident 2 had diagnoses of but not limited to a skin tear of the lower leg without complication, pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) with left lower leg weakness. During a review of Resident 2'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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-01-14 · 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 and interview the facility failed to ensure one of one ice machines in the facility kitchen was clean. This deficient practice had the potential to result in an outbreak of food borne illness (illness caused by food contaminated with germs). Findings: During an observation of one of one ice machine in the facility kitchen and interview on 1/12/2024 6:09 p.m., with the Food Service Lead (FSL), the ice machine bin was opened, the front panel interior bin was wiped with a clean paper towel, and dirt (dark gray colored) residue was noted. The KL stated the ice machine was dirty and it should be clean. During an interview on 1/13/2024 at 12:15 p.m. with the Patient Services Manager, Food & Nutrition Services (PSM), PSM stated the ice machine should be clean as indicated in the facility policy. During a review of the facility policy and procedure titled, Dispensing Ice, dated 10/6/2020, the policy indicated the food and nutrition services department prepares and dispense ice under strict procedures to prevent the transmission of disease. The policy indicated the ice…

    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 · F2024-01-14 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to address/ implement facility assessment elements when: a. The facility failed to include the Infection Prevention Nurse (IPN) dedicating mandated hours in the Transitional Care unit (TCU) for 40 of 40 residents in the facility assessment. b. The facility failed to obtain an offsite contract for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) center as indicated in the facility assessment. c. The facility failed to implement Certified Nurse Assistants' (CNA) 1 hour in service education to be provided twice per month, including dementia management, abuse/neglect, and patient rights and responsibilities as indicated in the facility assessment. These deficient practices had a potential to result in the provision of inadequate care and services to the facility's resident population. Findings: a. During an interview on 1/13/2024 at 12:59 p.m. with the IPN, the IPN stated she was responsible for the whole hospital, and she was the manager for the whole…

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

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · E2024-01-14 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain informed consent (process by which a healthcare provider educates a resident about the risks and benefits, and alternatives of a given procedure or intervention) prior to the administration of psychotropic drugs (drug that affects brain activities associated with mental process and behavior) for two out of three sampled residents (Resident 119 and 67) as indicated in the facility's policy and procedure (P&P). These deficient practices resulted in the violation of residents' right to be informed in advanced by the physician of the risk and benefits of the drug and treatment alternatives. Findings: a. During a review of Resident 119's Registration Record, the record indicated the resident was admitted to the facility on [DATE]. During a review of Resident 119's History and Physical (H&P), dated 1/10/2024, the H&P indicated Resident 119 had a history of anxiety (feeling of fear, dread, and uneasiness) and stress at home. The H&P indicated Resident…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-14 · tag F0761 — failed to label and store drugs safely — pattern
    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 During an observation, interview and record review the facility failed to store medication in a locked compartments and not left at residents' bedside for two of four sampled residents (Resident 170 and 171). This failure had the potential for medication errors, and lack of oversight for Resident 170 and 177. Findings: During a review of Resident 170's Registration Record, the Registratin Record indicated Resident 170 was admitted to the facility on [DATE] with diagnoses including weakness and fall secondary to orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down). During a review of Resident 170's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/10/2024, the MDS indicated Resident 170 had intact cognition (ability to learn, remember, understand, and make decision). The MDS indicated Resident 170 required supervision with oral hygiene and personal hygiene, moderate assistance with toileting, bed mobility, transfers,…

    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 · D2024-01-14 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 observation, interview and record review the facility failed to ensure one of five sample residents (Resident 8) fingernails were clean. This deficient practice had the potential to result in a violation of resident's right to a dignified existence which can result in a negative psychosocial wellbeing. Findings: During a review of Resident 8's Registration Record, the record indicated the resident was admitted to the facility on [DATE]. During a review of Resident 8's History and Physical (H&P), dated 12/4/2023, the H&P indicated Resident 8 had a history of hypertension (condition in which the force of the blood against the artery walls -blood vessels that distribute blood to the entire body- is too high), alcohol abuse, anxiety (feeling of dread or worry), supraglottic (upper part of the hollow tube in the middle of the neck) mass (abnormal solid growth) and had surgery 10/12/2023. During a review of Resident 8's Minimum Data Set ([MDS]-a standardized assessment and care screening tool ), dated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-14 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an interview and record review the facility failed to include resident and resident representative in Interdisciplinary ([IDT]- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) care planning and informed of any changes in care, treatment, and interventions for one of four sampled residents (Resident 166). This failure had the potential to violate Resident 166 and resident representative right to be an active participant to Resident 166's care. Findings: During a review of Resident 166's Registration Record, the Registration Record indicated Resident 166 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of altered mental status. During a review of Resident's 166's Discharge Summary (from [GACH] General Acute Care Hospital) dated 1/10/2024 indicated Resident 166 with diagnoses including glioblastoma (malignant tumor affecting the brain or spine) type 2 diabetes (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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-14 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 develop a baseline care plan addressing assistance for feeding for one (1) of four (4) sampled residents (Resident 63). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 63 and negatively impact the resident's physical and psychosocial well-being. Findings: During a review of Resident 63's Registration Record, the Registration Record indicated Resident 63 was admitted to the facility on [DATE]. Resident 63's diagnoses included hypertension (high blood pressure), diabetes mellitus (chronic disease that impairs blood sugar regulation in the body), and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). During a review of Resident 63's History and Physical (H& P) dated 1/8/2024, the H&P indicated Resident 63 was alert and oriented and able to move extremities. During a record review of the Speech Therapist (ST) notes dated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-14 · 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 interview and record review, the facility failed to develop a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) and person-centered care plans for two out of four sampled residents Resident 163 and 166). 1. Ensure Resident 163 who had pain on her left ankle develop specific interventions to address pain medications and interventions to alleviate (lessen) her pain. 2. Ensure Resident 163 who have an indwelling foley catheter were care planned to assess continued need of indwelling catheter. 3. Ensure Resident 166 who was had a care plan initiated for receiving Decadron (medication used to decreased swelling of the brain) was tapered (lowering of doses) and Keppra (medication used to treat seizures [ burst of uncontrolled electrical activity between brain cells]) develop specific intervention including monitoring adverse reactions and precautions. These failures had the potential for 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-14 · 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 During an observation., interview and record review Physical Therapy (PT-health specialist that treat residents to improve movement ) 1 failed to apply gait belt (assistive device which can be used to help safely transfer a resident from a bed to a wheelchair, assist with sitting and standing, and help with walking around) to one of four sampled residents ( Resident 177). This failure had the potential for increased risk of fall for Resident 177. Findings: During a review of Resident 177's Registration Record, the Registration Record indicated Resident 177 was admitted to the facility on [DATE] with diagnosis of right hip arthroplasty (a surgical procedure in which surgeon removed the diseased parts of the hip joint and replaced them with new). During an observation on 1/13/24 at 9:24 a.m. in the hallway, observed Resident 177 walking in the hallway with a front wheeled walker (assistive device for walking) . PT 1 was on Resident 177 right side holding Resident clothing while walking. Observed a family member…

    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 · D2024-01-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 a resident with an indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) was assessed for continued need and removed according to facility's policy and procedure (P&P) for one of four sampled residents (Resident 163). This failure resulted in continued discomfort to Resident 163 and had the potential for Resident 163 to have catheter associated urinary tract infection (CAUTI- a urinary tract infection [ UTI- an infection in any part of the urinary system, the kidneys, bladder, or urethra] associated with urinary catheter use). Findings: During a review of Resident 163's Registration Record, the Registration Record indicated Resident 163 was admitted to the facility on [DATE] with diagnoses of left ankle sprain (an injury that occurs when the ankle rolls, twists, or turns in an awkward way). During a review of Resident 163's History and Physical (H&P), the H&P indicated diagnoses…

    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 · D2024-01-14 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary care and services on one of four sample residents (Resident 63) to prevent complications during feeding by: a. Failing to obtain a physician's order for feeding assistance for Resident 63. b. Failing to create a comprehensive resident centered care plan indicating interventions to be implemented while feeding Resident 63 to prevent complications like aspiration (accidentally inhaling food or liquid through vocal cords into the airway) and choking (when person can't speak, cough, or breath because something is blocking the airway). This failure had the potential to result in Resident 63 aspirating and choking while eating. Findings: During a review of Resident 63's Registration Record, the Registration Record indicated Resident 63 admitted to the facility on [DATE]. Resident 63's diagnoses including hypertension (the force of the blood flowing through blood vessels is consistently too high), diabetes mellitus (chronic…

    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 · D2024-01-14 · 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 provide pain management for two of two sampled residents (Resident 119 and 163) consistent with the facility's policy and procedure when: a. The facility failed to ensure Resident 119's pain was assessed before and after pain medication was administered. b. The facility failed to communicate with Resident 163'S physician regarding pain management of her left ankle pain. c. The facility failed to develop an individualized comprehensive care plan to address Resident 163 pain management. These deficient practices had the potential to result in a poor pain management that can affect physical and psychological wellness. Findings: a. During a review of Resident 119's Registration Record, the record indicated the resident was admitted to the facility on [DATE]. During a review of Resident 119's History and Physical (H&P), dated 1/10/2024, the H&P indicated Resident 119 had a history of gastroesophageal reflux disease (when stomach acid repeatedly…

    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 · D2024-01-14 · 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 observation, interview, and record review the facility failed to ensure one (1) of four (4) sampled residents (Resident 63) was free from significant medication errors when: a. The facility failed to ensure Resident 63's medication was not left at the bed side table; and b. The facility failed to ensure six of Resident 63's medication on 1/12/2024 were administered on time. This deficient practice of leaving medication at the bedside had the potential for other staff, visitors, or residents to access prescription medication at any time. This deficient practice of not administering six medications on time had the potential to result in untoward effects to Resident 63. Findings: During a review of Resident 63's Registration Record, the Registration Record indicated Resident 63 was admitted to the facility on [DATE]. Resident 63's diagnoses included hypertension (high blood pressure), diabetes mellitus (chronic disease that impairs blood sugar regulation in the body), anemia (a condition that develops when…

    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 · D2024-01-14 · 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 and interview the facility failed to ensure the opened orange juice, apple juice, and vegetable salad were labeled with the residents' name, room number, and date it was opened in two out of two resident refrigerators in the Transitional Care Unit (TCU). These deficient practices had the potential to result in contamination of residents' food items which can cause food-borne illnesses (food poisoning). Findings: During a concurrent observation and interview on 1/12/2024 at 8:26 p.m. with Registered Nurse 3 (RN 3), in the TCU, two resident refrigerators were observed. The resident refrigerator in the pantry area was noted with an opened orange juice and apple juice. The juices did not have a label with the residents' names, room numbers, and dates opened. RN 3 stated all juices should be labeled with date opened because all juices will be discarded within 72 hours of open date. The resident refrigerator in the dining/activity room was observed and an opened vegetable salad was noted with no label of the resident's name, room number, and date it was opened. RN 3…

    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 before2024-01-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow infection control to prevent the spread of infection when: 1. Plant Engineer exited Resident 163's room who was on contact isolation (precautions intended to prevent transmission of infectious agents) with isolation gown and gloves and failed to do hand hygiene (cover both hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) after doffing (remove) personal protective equipment (PPE-equipment used to prevent or minimize exposure to hazards). This failure had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents and staff at risk for infection. Findings: During a review of Resident 163's Registration Record, the Registration Record indicated Resident 163 was admitted to the facility on [DATE] with diagnoses of left ankle sprain (an injury that occurs when the ankle rolls,…

    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 · Dcited before2024-01-14 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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 implement their protocol for Antibiotic (drug to treat infection) Stewardship (effort to measure and improve how antibiotics, medications that fight infections, are prescribed) program for one of three sampled residents (Resident 163). Resident 163 was prescribed Piperacillin-tazobactam (antibiotic) 3.375 gram (gm-unit of measurement) intravenous piggyback (IVPB-small bag of solution attached to a primary infusion line) every eight hours without any laboratory confirmation to screen for a Urinary Tract Infection (UTI, an infection in any part of the urinary system, the kidneys, bladder, or urethra) and without a stop date. This deficient practice had the potential to result in the resident developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 163's Registration Record, the Registration Record indicated Resident 163 was admitted to the facility 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-14 · tag F0882 — isolated
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review: a.The facility failed to ensure the Infection Preventionist Nurse (IPN) implemented the antibiotic (drug to treat infection) stewardship program (effort to measure and improve how antibiotics, medications that fight infections, are prescribed) for twenty-nine of twenty-nine sampled residents. b.The facility failed to ensure the (IPN) dedicated mandated hours to the Transitional Care Unit (TCU) as required by federal and state regulations. This deficient practice resulted in a lack of oversight in the Antibiotic (drug to treat infection) Stewardship (effort to measure and improve how antibiotics, medications that fight infections, are prescribed) program and Infection Control and Prevention Program for 29 out of 29 sampled residents in the TCU. Findings: During the entrance conference with the Director of Nursing (DON) on 1/12/2024 at 5:49 p.m., the DON stated there was no designated full time Infection Preventionist in the TCU. The designated IPN was the manager of the Infection Control Department. During an interview on 1/13/2024 at 12:59 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-14 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 173) received education regarding the benefits and potential side effects of the pneumococcal vaccine (medication help protect against infection that can cause serious illness like pneumonia [infection of the lungs]) before the vaccine was administered on 1/12/ 2024. This deficient practice had the potential to result in misinformation that can negatively affect physical and mental wellness. Findings: During a record review of the Resident 173's Registration Record, the record indicated the resident was admitted to the facility in 1/5/2024. During a record review of Resident 173's History and Physical (H&P), dated 12/29/2023, the H&P indicated Resident 173 was diagnosed with left pneumothorax (collapsed lung where air leaks between the lungs and chest wall), acute hypoxic respiratory failure (impaired gas exchange between the lungs and the blood and not enough oxygen in blood), coronary artery disease (damage or disease in the heart's major blood vessels) and hypertension…

    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 · E2023-11-06 · tag F0825 — pattern
    Provide or get specialized rehabilitative services as required for a 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 provide occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person ' s capability to participate in everyday life activities) and/or physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) treatments based on the physician ' s order and therapy treatment plan for three of four sampled residents (Residents 1, 2, and 4). These deficient practices had the potential to delay recovery and discharge planning for Residents 1, 2, and 4. Findings: a. A review of Resident 1 ' s Registration Record indicated Resident 1 admitted to the facility on [DATE] for right hip replacement (procedure to replace diseased part of the hip with an artificial part). A review of Resident 1 ' s Resident Care Team Meeting notes dated 11/1/23 and updated on 11/6/23 indicated Resident 1 required moderate assistance with bed mobility, maximum 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-01-19 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to ensure staffing information was posted and placed in a visible and prominent place daily. This deficient practice resulted in unavailable information for the number of staff and actual hours worked daily that is visible for residents, staff and visitors. Findings: During an observation 1/19/2025 at 11:30 a.m., no visible staffing information was found on station 1 or station 2. During an observation on 1/19/2025 at 11:30 a.m., no visible staffing information was found in the lobby or upon entrance to the unit. During an interview on 1/19/2025 at 11:49 a.m., with Registered Nurse (RN) 1, RN 1 stated there is no staffing information visibly posted for the residents and visitors. During an interview on 1/19/2025 at 11:52 a.m., with the Director of Staff Development (DSD), the DSD stated that there is a staffing information form posted in station 1 but is not facing outward for residents and visitors to see and probably should be. During an interview on 1/19/2025 at 3:42 p.m., with the Director of Nursing (DON), the DON 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.

    Nursing and Physician Services 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.

Who owns this facility

Owner / managerTypeRoleSince
DOBIE, LINDAIndividualCORPORATE DIRECTORsince 11/01/2023
FIORITO, ERINIndividualCORPORATE DIRECTORsince 11/01/2023
HALL, SHANNAIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/27/2025
MCRAE, ELAINEIndividualCORPORATE DIRECTORsince 11/01/2023
MILEFCHIK, ERICIndividualCORPORATE DIRECTORsince 11/15/2024
SENNER, CONNIEIndividualCORPORATE DIRECTORsince 11/01/2023
SHAY, HEATHERIndividualCORPORATE DIRECTORsince 11/01/2023
ALI-JONES, RASHAANIndividualCORPORATE OFFICERsince 11/15/2024
BERZ, DEREKIndividualCORPORATE OFFICERsince 11/01/2023
COBB, INGRIDIndividualCORPORATE OFFICERsince 11/01/2023
CRANE, KATHLEENIndividualCORPORATE OFFICERsince 11/15/2024
DUPERRON, DONNAIndividualCORPORATE OFFICERsince 11/15/2024
GEIGER, GREGORYIndividualCORPORATE OFFICERsince 05/01/2024
GRAY, ZACHARYIndividualCORPORATE OFFICERsince 11/01/2023
HOBBS, KEITHIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 11/01/2023
HOHM, JOEIndividualCORPORATE OFFICERsince 11/15/2024
KRAMER, SHERRYIndividualCORPORATE OFFICERsince 05/01/2013
LARSON, WILLIAMIndividualCORPORATE OFFICERsince 01/07/2011
LEACH, CRAIGIndividualCORPORATE OFFICERsince 11/01/2023
REID, BERNEDETTEIndividualCORPORATE OFFICERsince 11/01/2023
ROGERS, CHRISTOPHERIndividualCORPORATE OFFICERsince 11/01/2023
SCHENASI, LAURAIndividualCORPORATE OFFICERsince 11/01/2023
SHIN, VICTORIAIndividualCORPORATE OFFICERsince 11/15/2024
UNDERWOOD, TRACYIndividualCORPORATE OFFICERsince 11/15/2024
WELCH, SUSANIndividualCORPORATE OFFICERsince 11/15/2024
WRIGHT, MARYIndividualCORPORATE OFFICERsince 11/01/2023
CEDARS-SINAI HEALTH SYSTEMOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 02/01/2018
TORRANCE HEALTH ASSOCIATION INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/25/1984
TARNG, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/12/2025

CMS files one row per role, so the 33 rows in the source record cover these 29 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

What families pay in CA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555599. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-15, 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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