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Heritage Park Nursing Center

275 Garnet Way, Upland, CA 91786 · For profit - Corporation · 70 certified beds · (909) 949-4887 Medicare & Medicaid certified

Call the home — (909) 949-4887 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 20261 actual-harm citation
Insights

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

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 (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (21) — 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) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
300 N Euclid Ave · (909) 920-9100 · Call to confirm hours
Pharmacy
100 W Foothill Blvd · (909) 982-8908 · Call to confirm hours
Grocery
285 N Euclid Ave · (909) 949-7488 · Call to confirm hours
Park
526 E 8th St · (909) 931-4280 · 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
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.2%10.2%15.4%better
Long-stay residents who lose too much weight0.5%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.4%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened3.4%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication6.3%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers0.0%4.3%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control1.3%10.2%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table4.0%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission22.9%23.0%22.6%typical
Short-stay residents with an outpatient ER visit11.4%11.2%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.572.251.67typical
Long-stay outpatient ER visits per 1,000 resident days1.031.571.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

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

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

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

62.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 144 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.2%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
61.5%U.S. median 56.6%
Met the expected recovery
0.61U.S. median 0.31
Therapy hours / resident / day
0.31hours / resident / day
Physical therapy
0.27hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 61.5% 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 96 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 0.61 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNF62.2%CMS range 54.6–70.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 7.5–14.410.7%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 discharge61.5%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 discharge49.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge58.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 4.3–12.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.291.02Oct 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

0.38
RN hours/ resident / day
1.25
LPN hours/ resident / day
2.16
Aide hours/ resident / day
3.79
Total nurse hours/ resident / day
0.21
RN hoursweekends
42.0%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 70 beds and averages 67.0 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.29 hrs/resident/day on weekends vs 3.99 on weekdays — 18% thinner on weekends. RN hours go from 0.45 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as 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 (2025-06-19)
2
at the previous standard inspection (2024-05-16)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · Gcited before2025-04-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards (refer to elements of the resident environment that have the potential to cause injury or illness) for one of three sampled residents (Resident 1) when Resident 1 ingested a cleaning solution left by a housekeeper (HSK 1) in Resident 1's room on March 2, 2025. This failure resulted in Resident 1 to be transferred to the General Acute Care Hospital (GACH) for higher level of care and suffered from additional health issues. Findings: During a review of Resident 1's admission Record (contains demographic and medical information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of end-stage renal disease (ESRD- serious condition where the kidneys are no longer able to filter waste and excess fluid from the blood treatment used to remove toxins), heart failure (when the heart is not pumping blood as well as it should) and non-ST elevation myocardial infarction…

    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 · D2026-05-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to protect against physical abuse for one of three sampled residents (Resident 1) when a Certified Nursing Assistant (CNA 1) forcefully sat Resident 1 in the wheelchair by Resident 1's pants, then pushed the wheelchair into the room and closed the door behind Resident 1. This failure had the potential to cause physical injury, emotional distress, and a decline in Resident 1's sense of safety and well being.Findings: An unannounced visit was made to the facility on May 12, 2026, at 1:28 PM, to investigate a facility reported incident regarding an allegation of physical abuse. A review of Resident 1's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of February 14, 2025. Resident 1 had diagnoses that included paranoid schizophrenia (a chronic mental health disorder characterized by intense, irrational suspicions (paranoia), auditory hallucinations, and delusions (false beliefs that someone or something is going to cause them harm)). A review of a Mental Health…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 their policy for Psychotropic (drugs that affect the mind, emotions, and behavior) Medication Use was implemented for one of two residents reviewed for unnecessary medications (Resident 38). This failure had the potential to place Resident 38 at risk of staff not identifying the effectiveness of the psychotropic medication and missing potential side effects placing Resident 38 at risk for adverse health outcomes. Findings: During a review of Resident 38's admission Record (contains demographic and medical information) it indicated Resident 38 was admitted to the facility on [DATE], with the diagnoses of intracapsular fracture of left femur (a break in the upper part of thigh bone), acute respiratory failure with hypoxia (do not have enough oxygen in blood), and major depressive disorder (a persistent sadness, loss of interest). During a review of Resident 38's Physician Order, dated March 6, 2025, it indicated Resident 38 had a physician order…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their medication administration policies and procedures when: 1. A Licensed Vocational Nurse (LVN 2) administered Metoprolol (medication used to lower blood pressure) Extended Release (ER- type of medications designed to be swallowed whole to allow the medication to work gradually over time) crushed to Resident 34. 2. The controlled drug inventory (when a nurse signs verifying that the nurses performed controlled medication counts during shift change- system in place used to prevent discrepancies in narcotic medication counts) had missing signatures on multiple shifts for two carts on Unit 2. These failures had the potential to place Resident 34 at risk for adverse medication side effects and place the facility at risk for potential diversion (illegal distribution of controlled medications for illicit use) of controlled medications by staff in a highly vulnerable population of 19 residents in Unit 2. Findings: 1. During a review…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · 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 infection control practices when a License Vocational Nurse 2 (LVN 2) did not wear PPE (Personal Protective Equipment, such as gloves and gowns) as required under EBP (Enhanced Barrier Precautions, used to prevent the spread of resistant infections) while providing treatment to a resident in EBP isolation (Resident 117). This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasites) to another 65 vulnerable residents and staff in the facility. Findings: During a review of Resident 117's admission Record (clinical record with demographic information), the admission Record indicated Resident 117 was admitted on [DATE], with diagnoses of aftercare following surgery on the digestive system (an operation that fixes or treats problems in organs like the stomach, intestines, or other parts that help break down food) and encounter for attention to gastrostomy (a small opening made…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-23 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure for investigating an allegation of suspected physical abuse for one of three sampled resident (Resident 3), when the facility did initiate an investigation for the incident within specified timeframes after Resident 3 reported an alleged abuse by another resident to the Administrator on April 2, 2025. This failure has the potential to jeopardize Resident ' s 3 health, safety, and well-being at risk and the other vulnerable population of 69 residents. Findings: A review of State of California Form 341 [Suspected Dependent Adult/Elder Abuse form], dated April 10, 2025, indicated . While Ombudsman [a person who helps solve complaints and problems between people and organizations, making sure things are fair] was visiting the facility [Resident 3] reported to the Ombudsman that [Resident 2] forced sex on her [Resident 3] last week on a Wednesday night (4/2/25 [April 2, 2025]) between 10:30pm-11:00pm while she was sleeping.…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-16 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    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, record review, facility policy review, and review of the Centers for Medicare and Medicaid Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected preadmission screening and resident review (PASRR) information for 3 (Residents #2, #26, and #61) of 6 residents reviewed for PASRR requirements. Findings included: A facility policy titled, Minimum Data Set (MDS) - Resident Assessment Instrument (RAI), dated 11/2017, revealed, 1. The facility shall complete a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by the Center of Medicaid and Medicare [NAME] (CMS), regardless of payer source, in facilities certified by the Medicare/Medicaid programs following the timeframes and instructions specified in the current CMS RAI Manual. The policy revealed, -Each responsible IDT [interdisciplinary team]…

    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 · D2024-05-16 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of a Level I preadmission screening and resident review (PASRR) for 1 (Resident #51) of 6 sampled residents reviewed for PASRR requirements. Specifically, Resident #59 had a diagnosis of schizoaffective disorder and major depressive disorder; however, the resident's Level I PASRR screening indicated the resident did not have a mental disorder. Findings included: A facility policy titled, admission Criteria, revised in 03/2019, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) [also referred to as PASRR] process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. An admission Record revealed the facility admitted Resident #51 on 03/11/2024 and readmitted the resident on 03/27/2024. According…

    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 · D2024-04-08 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an alleged sexual abuse for one of three sampled residents (Resident 2) by another resident to the local, state and agencies. This failure had the potential to place a clinically compromised resident (Resident 2)'s health, safety and well-being at risk. Findings: During review of Residents 2's admission Record (general demographics), the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder (a condition of mental illness), major depressive disorder (a condition of feeling of sadness) and hypertension (a condition with a high blood pressure). During an interview on April 8, 2024, at 2:30 PM, with the Director of Nursing (DON), the DON stated, We do investigations and report to the appropriate agencies including CDPH (California Department of Public Health). When asked who does the reporting, the DON stated, The Administrator usually does it, but all licensed staff and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-27 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    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 immediate measures were put into place to provide protections to one of three sampled resident (Resident 3) when a License Vocational Nurse (LVN) and a Program Counselor (PC) were not suspended immediately after an alleged abuse to Resident 3 was reported on February 14, 2024. This failure had the potential for further abuse, neglect, exploitation, or mistreatment in a vulnerable population of 68 residents as the alleged perpetrators, LVN and PC, continued to have access to the alleged victim, Resident 3, and to other residents while the investigation was still in process. Findings: During a review of Resident 3 ' s admission Record (clinical record with demographic information), it indicated Resident 3 was admitted to the facility on [DATE], with diagnoses of schizoaffective disorder (a chronic mental health condition that affects your mood and perception of reality) bipolar type (with episodes of manic that can shift to major…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) who eloped (leaving a safe area without authorization and/or appropriate supervision from the facility) was assessed to prevent or/and to minimize the risk for recurrence of elopement. This failure had the potential to cause a delay in identifying care and support needs which could place Resident 3 at risk for recurrence of elopement and at risk for injuries related to elopement. Findings: During a review of Resident 3 ' s medical record , the admission Record (contains demographic and medical information), indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included of schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), delusional disorder (a type of mental health condition in which a person can't tell what's real from what's imagined), and bipolar disorder (a mood disorder that can cause intense mood swings). A review of a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2024-01-26 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure their closed observation protocol (a protocol for observing residents who are at risk for harm every fifteen minutes) documentation was complete in accordance with the facility ' s policy and procedure (P&P) for one resident (Resident 1) when Resident 1 returned to the facility after he eloped on January 7, 2024. This failure has the potential to result in Resident 1 to be at risk for further elopement without supervision of his whereabouts which could increase Resident 1 ' s risk for harm. Findings: During an interview on January 19, 2024, at 11:08 AM, with Resident 1, Resident 1 stated he left the facility because the voices made him uncomfortable in the facility. Resident 1 further stated he opened the emergency exit door by pushing the door [LP1] [SJ2] and running out. Resident 1 stated he came back to the facility because he needed a roof over his head. During an observation on January 19, 2024, at 11:11 AM, with Resident 1, Resident 1 demonstrated how he pressed the fire alarm then proceeded to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-11-04 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: a. Stacked cups were stored wet. b. The ice machine had black build up in the ice chute (where ice exits the area where its formed and drops into the ice bin). These failures had the potential for bacteria to growth and cause foodborne illness in a highly susceptible population of 57 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview, with the Dietary Supervisor (DS), on November 1, 2022, at 8:10 AM, inside the kitchen, there were stacked cups stored wet. The DS stated the cups should have been air dried before stacking. During a concurrent interview and record review, with the DS, on November 1, 2022, at 8:30 PM, the DS reviewed the facility's policy and procedure (P&P) titled, Cleaning Dishes/ Dish Machine, dated 2017, which indicated, .10. Inspect for cleanliness and dryness and put dishes away if clean . 11. Dishes should not be nested…

    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 · E2022-11-04 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure information whether or not the resident has executed an advance directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated) was displayed prominently in the medical record for three of six residents (Residents 156, 33, and 46) reviewed for advance directives. This failure had the potential to result in a delay of treatment for life sustaining measures to be rendered against what Residents 156, 33, and 46 wanted. Findings: 1. During an observation, on November 1, 2022, at 10:38 AM, Resident 156 was in her room, lying down in bed. During a review of Resident 156's medical record, the admission Record (contains demographic and medical information), it indicated Resident 156 was admitted to the facility on [DATE], with diagnoses which included chronic systolic congestive heart failure…

    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 · D2022-11-04 · 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 dignity was maintained for two of six residents (Resident 4 and Resident 7) reviewed for urinary catheter (flexible tube inserted into the bladder to drain urine) when: 1. Resident 4's urinary catheter bag was not covered by a privacy bag (bag used to cover catheter bag). 2. Resident 7's urinary catheter bag was not covered by a privacy bag. These failures had the potential to compromise Residents 4 and 7's dignity and violate their rights to privacy, which could cause psychosocial harm and lead to low self-esteem, feeling irritated, sad, and anxious. Findings: 1. During a review of Resident 4's admission Record (clinical record with demographic information), it indicated Resident 11 was readmitted to the facility on [DATE], with diagnoses of type two diabetes (high sugar levels), chronic kidney disease stage 3 (moderate kidney damage), and cerebral infarction (disrupted blood flow to the brain). During a review of Resident 4's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-04 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure their splint (device applied to prevent or reduce contractures) application policy and procedure was implemented for one resident (Resident 23) reviewed for range of motion (ROM- full movement potential of a joint) when Resident 23's multiple splint application refusals were not addressed from December 2021 through October 2022. This failure placed Resident 23 at risk of further deformities and having decline in ROM. Findings: During an observation, on November 1, 2022, at 3:36 PM, Resident 23 was in his room, lying down in bed. Resident 23's right hand was contracted. He was not wearing a splint (a rigid or flexible device that maintains in position a displaced or movable part). During a review of Resident 23's medical record, the admission Record (contains demographic and medical information), indicated Resident 23 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the safety policies and procedures were implemented for one of three residents (Resident 29) reviewed for accidents when the facility did not provide Resident 29 floor mats as per physician's orders. These failures have the potential to increase the risk of further falls, injuries, and unmet care needs, which could threaten the welfare, health, and safety of Resident 29. Findings: A review of Resident 29's admission Record (contains demographic and medical information) indicated Resident 29 was admitted to the facility on [DATE], with diagnoses of Parkinson's disease (brain disorder that causes unintended movements) and a history of falling. During a review of Resident 29's physician's order, dated May 9, 2021, indicated Monitor placement of floor mats to the left side of the bed and the right side of the bed for safety. Every shift for fall precautions. During a review of Resident 29's care plan initiated on May 9, 2021,…

    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 · D2022-11-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe oxygen administration were provided in accordance with the physician's orders and facility's policies and procedures for one resident (Resident 156) reviewed for respiratory care when Residents 156's nasal cannula (a device which delivers oxygen utilizing a tube) was not labeled. This failure had the potential to place Resident's 156 at risk for developing a respiratory infection. Findings: During a review of Resident 156's medical record, the admission Record (contains demographic and medical information), indicated Resident 156 was admitted to the facility on [DATE], with diagnoses which included chronic systolic congestive heart failure (disease in which heart cannot pump blood efficiently and makes it difficult to breathe), and hypertensive heart disease with heart failure (heart failure due to elevated blood pressure). A review of Resident 156's physician's orders, dated October 18, 2022, indicated, Oxygen: At 2L/min…

    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 · D2022-11-04 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure medications and medication carts (used to transport medications from resident rooms; often come equipped with locking drawers, adjustable height) were properly secured when one of six medication carts (IV [Intravenous- method of putting fluids, including drugs, into the bloodstream] medication cart) was found unlocked and unattended by a licensed nurse. These failures had the potential to compromise the security of medication for potentially unauthorized staff and resident around the area could access it in a highly vulnerable population of 64 residents. Findings: During an observation, on November 3, 2022, at 7:10 AM, an IV medication cart was outside of room [ROOM NUMBER], near the nurse's station. A Registered Nurse (RN) went inside room [ROOM NUMBER], and left the IV medication cart key lock (device that is pushed in to indicate the medication cart is locked) propped out. The IV medication cart…

    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 · D2022-11-04 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly and in accordance with their policy and procedure when garbage was found on the ground by the garbage storage area . This failure had the potential for the harborage or breeding place of insects and rodents that could affect the health and safety of a highly vulnerable population of 64 residents. Findings: During a concurrent observation and interview with the Maintenance Supervisor (MS), on November 1, 2022, at 3:20 PM, the outdoor garbage storage area was inspected. There were diapers, used gloves, a bag of cloth towels, two empty soda cans, plastic straws, and plastic knives found on the ground of the outdoor garbage area. The MS stated it should have been clean and free of garbage. During a concurrent interview and record review, with the MS, on November 1, 2022, at 2:00 PM, the MS reviewed the facility's policy and procedure (P&P) titled, Dispose of Garbage and Refuse, dated November 2017, which indicated, .3. Garbage storage shall be maintained in a sanitary…

    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 · D2022-11-04 · tag F0888 — isolated
    Ensure staff are vaccinated for COVID-19
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their infection control program to help prevent the spread of COVID-19 virus (a highly infectious respiratory disease) and other communicable diseases when one unvaccinated staff (Licensed Vocational Nurse - LVN 2) did not wear a respirator mask (a filtering facemask used to protect the wearer from fine particles including viruses) on November 3, 2022. This failure had the potential to cause harm to the 64 residents residing within the facility by causing cross contamination of the environment and increasing the risk of exposure and spread of the COVID-19 virus. Findings: During an observation and concurrent interview, on November 3, 2022, at 5:30 AM, LVN 2 came out of room [ROOM NUMBER], stood infront of the medication cart, and started to work on the computer. LVN 2 had on a surgical mask (or procedure mask, loose-fitting mask that provide partial protection from airborne diseases) covering her nose and mouth. She was not…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to GENERATIONS HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 54.1+0.9 vs chain
Health inspection 5 of 53.6+1.4 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 5 of 54.6+0.4 vs chain
The other 26 homes this chain runs (chain average 4.1★, per CMS)
2 of 5Horizon Health & Subacute CenterFresno, CA 2 of 5Temecula Healthcare CenterTemecula, CA 2 of 5Walnut Creek Skilled Nursing & Rehabilitation CentWalnut Creek, CA 3 of 5Canyon Oaks Nursing And Rehabilitation CenterCanoga Park, CA 3 of 5English Oaks Convalescent & Rehabilitation HospitaModesto, CA 3 of 5Newport Nursing And Rehabilitation CenterNewport Beach, CA 3 of 5Smith Ranch Skilled Nursing & Rehabilitation CenteSan Rafael, CA 3 of 5The Bradley GardensSan Jacinto, CA 4 of 5Bayberry Skilled Nursing & Healthcare CenterConcord, CA 4 of 5Castle Manor Nursing & Rehabilitation CenterNational City, CA 4 of 5Cedar Crest Nursing And Rehabilitation CenterSunnyvale, CA 4 of 5Coronado Ridge Skilled Nursing & Rehabilitation CeHenderson, NV 4 of 5Gramercy CourtSacramento, CA 4 of 5Lompoc Skilled Nursing & Rehabilitation CenterLompoc, CA 5 of 5Anberry Nursing And Rehabilitation CenterAtwater, CA 5 of 5Arbor Hills Nursing CenterLa Mesa, CA 5 of 5Bradley CourtEl Cajon, CA 5 of 5Friendship Manor Nursing & Rehab CenterNational City, CA 5 of 5Kearny Mesa Convalescent And Nursing HomeSan Diego, CA 5 of 5Lakeside Special Care CenterLakeside, CA 5 of 5Lawton Skilled Nursing & Rehabilitation CenterSan Francisco, CA 5 of 5Pleasanton Nursing And Rehabilitation CenterPleasanton, CA 5 of 5Plum Tree Care CenterSan Jose, CA 5 of 5Siena Skilled Nursing & Rehabilitation CenterAuburn, CA 5 of 5Stanford Court Skilled Nursing & Rehab CenterSantee, CA 5 of 5Vista Manor Nursing CenterSan Jose, CA

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 / managerTypeRoleSince
BMO BANK NATIONAL ASSOCIATIONOrganization5% OR GREATER SECURITY INTERESTsince 09/20/2023
MASTROCOLA, LOISIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICERsince 02/01/1998
OLDS, THOMASIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 02/01/1998

CMS files one row per role, so the 6 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.7M
Net patient revenuemost recent cost report
-36.0%
Operating marginrevenue minus expenses
$1.3M
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 4%Medicare 19%Other / private 77%

This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$689per resident / day
operating cost
$20,950per month
≈ monthly operating cost
$507per day
avg. revenue, all payers

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

What families pay in CA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555514. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-19, 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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