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Vacaville Convalescent and Rehabilitation Center

585 Nut Tree Ct., Vacaville, CA 95687 · For profit - Corporation · 120 certified beds · (707) 449-8000 Medicare & Medicaid certified

Call the home — (707) 449-8000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Sep 2024Behavioral-health or dementia-care citation — no harm found (F0744)$7,976 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $7,976 in federal fines (most recent 2024-02-06)

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.

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
421 Nut Tree Rd · (707) 646-4100 · Call to confirm hours
Pharmacy
1500 Helen Power Dr · (707) 449-3638 · Call to confirm hours
Grocery
130 Nut Tree Pkwy · (707) 447-1791 · Call to confirm hours
Park
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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 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 fell from 5 to 4 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 rating4★
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 increased11.9%10.2%15.4%better
Long-stay residents who lose too much weight2.5%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.7%0.8%0.9%better
Long-stay residents with a urinary tract infection1.7%1.2%2.0%better
Long-stay residents with depressive symptoms3.6%7.3%6.5%better
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 injury2.2%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened7.7%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication6.9%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers12.0%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control18.1%10.2%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table11.3%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.2%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine99.4%93.2%79.4%better
Short-stay residents rehospitalized after admission25.1%23.0%22.6%worse
Short-stay residents with an outpatient ER visit15.7%11.2%12.0%worse

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.

51.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 418 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.9%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
50.4%U.S. median 56.6%
Met the expected recovery
0.66U.S. median 0.31
Therapy hours / resident / day
0.34hours / resident / day
Physical therapy
0.30hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 50.4% 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 240 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 0.66 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 27% 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 SNF51.9%CMS range 48.5–56.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 8.8–14.010.7%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 discharge50.4%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 discharge40.0%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 discharge50.4%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 identified94.1%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 setting20.3%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 discharge97.8%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 stay0.3%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 worsened0.7%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 hospitalization6.2%CMS range 3.9–9.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.901.02Oct 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

0.96
RN hours/ resident / day
1.20
LPN hours/ resident / day
3.53
Aide hours/ resident / day
5.68
Total nurse hours/ resident / day
0.75
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 120 beds and averages 92.9 residents a day — about 77% occupied, or roughly 27 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 5.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.53 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.92 hrs/resident/day on weekends vs 6.00 on weekdays — 18% thinner on weekends. RN hours go from 1.05 to 0.75 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

5
deficiencies at the latest standard inspection (2026-03-06)
8
at the previous standard inspection (2024-12-06)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · D2026-04-22 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident1) in a census of 88 was free from restraints when a bedsheet was knotted around his torso and tied in the back of his wheelchair (W/C) so he could not untie it.This failure resulted in Resident 1 being unable to independently free himself from the wheelchair.Findings:Resident 1 was admitted to the facility in the spring of 2026 with diagnosis which included vascular dementia with behavioral disturbance (a decline in thinking and memory caused by reduced blood flow to the brain-often due to strokes that is accompanied by significant, out-of-character changes in personality, mood, and conduct) and a history of falling.During a review of Resident 1's Baseline Care Plan (BCP), dated 4/8/26 - 4/9/26, the BCP indicated Resident 1 used a wheelchair, was cognitively impaired and had a history of falls.During a review of Resident 1's Plan of Care Note (POC, nurses notes), dated 4/9/26, the POC indicated Res [resident] noted by am [day shift] staff CNA [Certified Nurses…

    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 · Ecited before2026-03-06 · tag F0658 — failed to meet professional standards of care — pattern
    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

    Based on observation, interview and record review, the facility failed to provide care and services in accordance with the current professional standards of nursing practice for two of 24 sampled residents (Resident 40 and Resident 124), when:Wound care orders were not updated and implemented as written for Resident 40; and,Wound care orders were not updated and implemented per the physician's verbal order for Resident 124.These failures had the potential for Resident 40 and Resident 124 to receive inadequate wound care with increased risk of complications.Findings: 1. A review of Resident 40's admission Record (AR) indicated Resident 40 was admitted to the facility in February 2026 with diagnoses which included chronic osteomyelitis (a persistent, long-term bone infection leading to bone destruction) in the right arm and polyneuropathy (damage to multiple peripheral nerves in the hands and feet). During a review of Resident 40's Wound Care Plan (WCP), dated 3/2/26, the WCP indicated, Cleanse with normal saline (a sterile, isotonic solution), skin prep on periwound (area around 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 · E2026-03-06 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews the facility failed to ensure the facility garbage and refuse was properly contained for a census of 87, when two out of two dumpsters were continually left open and uncovered. This failure had the potential for pest infestations, environmental hazards and foul odors to affect the residents' surrounding environment.Findings: During an observation on 3/3/26 at 7:33 a.m. in the small parking lot adjacent to the facility kitchen, a gray metal dumpster was observed with the lid open. During a concurrent observation and interview on 3/3/26 at 8:35 a.m. with the Registered Dietician (RD) and the Dietary Services Supervisor (DSS), in the small parking lot, two large dumpers were observed uncovered. The RD and DSS confirmed one dumpster contained garbage and refuse, and the other dumpster contained cardboard for recycling. The RD and DSS confirmed dumpster lids needed to be closed to keep rodents away. During an interview on 3/6/26 at 1:04 p.m. with the Administrator (Admin), the Admin acknowledged the dumpster lids were difficult to close and remained…

    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 · D2026-03-06 · 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

    Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 42) was free from unnecessary medications, when Resident 42 was prescribed a psychotropic medication (any drug that affects behavior, mood, thoughts or perception) with no adequate indications. This failure had the potential to place Resident 42 at risk for adverse effects of the psychotropic medication.Findings: During a review of Residents 42's admission Record (AR), the AR indicated Resident 42 was admitted in late 2024 with diagnoses which included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities). During a review of Resident 42's Medication Review Report (MRR), dated 12/27/24, the MRR indicated. [Resident 42] has the Capacity to Make Medical Decision. During a review of Resident 42's Medication Review Report (MRR), dated 12/22/25, the MRR indicated a physician's order, Lorazepam [an antianxiety medication], 0.5 mg. tablet, by mouth every 8 hours as…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · 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

    Based on observation, interview, and record review, the facility failed to implement infection control and prevention practices when materials that had contact with room surfaces were brought from Resident 124's and Resident 129's rooms back to the clean treatment cart. This failure increased the potential for the spread of infections among residents in a census of 87.Findings: During a review of Resident 124's admission Record (AR), dated 3/5/26 (print date), the AR indicated that Resident 124 was admitted to the facility in February of 2026 with diagnoses which included bladder cancer and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 129's AR, dated 3/5/36 (print date), the AR indicated that Resident 129 was admitted to the facility in February of 2026 with diagnoses which included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and ESRD (End Stage Renal Disease-irreversible kidney failure). During an observation on 3/5/26 at 9:16 a.m. in Resident 124'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 · D2026-03-06 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure hazardous chemicals were secured and inaccessible to residents when a housekeeping closet containing cleaning chemicals was left unattended, with the key hanging on the wall next to the door. This deficiency increased the risk of unauthorized access to hazardous chemicals and potential harm to the residents. Findings: During a concurrent observation and interview on 3/6/26 at 1:13 p.m. with the Administrator (Admin) in the hallway near room [ROOM NUMBER], an unattended housekeeping closet with a key hanging next to the door was observed. The Admin opened the closet using the key on the wall, and the closet contained bleach and other cleaning chemicals. The Admin confirmed that leaving the key out increased the risk of unauthorized access to the chemicals, including confused residents who may be harmed by misuse of these chemicals. During a review of the facility's policy and procedure (P&P) titled, Hazardous Materials Management Program,, 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-06 · 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

    Based on observation, interview, and record review, the facility failed to ensure that medications were stored according to accepted professional principles for a census of 82 residents, when loose pills were found in a medication cart and medication refrigerators were not maintained. This deficiency had the potential for residents to have an increased risk of receiving compromised medications. Findings During a concurrent observation and interview on 12/4/24 at 2:07 p.m., with Licensed Nurse 2 (LN 2) of north hall medication cart A, 8 loose pills were found in the bottom of the medication drawer. LN 3 confirmed the presence of the loose pills and stated that loose pills could be accidently given to residents. During a concurrent observation and interview on 12/4/24 at 2:31p.m. of north station medication room with LN 1, LN 1 confirmed the medication refrigerator was: 1. noted to have thick ice buildup which prevented the freezer door to be opened, 2. puddles of water were seen at the bottom of the fridge and shelving, and 3. damage was noted on the external areas of the fridge. LN…

    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 · Ecited before2024-12-06 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when: 1. The wound treatment nurse (TN): took a container of medication from a resident's room and put back in the clean supply cart, failed to sanitize equipment between uses for different residents, and did not label wound dressings. 2. Housekeeping staff did not perform hand hygiene between cleaning different resident rooms and the same mop and sanitizing solution was used to clean multiple rooms. 3. Enhanced Barrier Precautions were not applied for residents with wounds and indwelling medical devices. These failures had the potential to result in infection spread among a facility census of 82 residents. Findings: 1. During wound treatment observation on 12/4/24 commencing at 1:55 p.m., the TN was observed providing wound care to Resident 141 and Resident 242. The TN brought supplies including…

    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 · E2024-12-06 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to ensure all Certified Nursing Assistants (CNAs) were provided mandatory abuse training when documentation for the required training was unavailable for the 13 CNAs assigned to the night (NOC) shift. This failure had the potential for all 82 residents in facility to experience physical, mental, or psychosocial harm. Findings: During an interview on 12/04/24 at 4:21 p.m. with the DSD, the DSD stated in-services were scheduled two times a week on Tuesday's and Thursday's from 2:30 p.m. to 3:30 p.m. When questioned if the DSD provided in-services to the NOC shift staff, the DSD did not provide a response. During an interview on 12/05/24 at 8:09 a.m. with the DSD, the DSD stated she tracked staff participation for required in-services by ensuring staff write their name and signature on a sign in sheet accompanying the in-service. The DSD confirmed the mandatory abuse prevention training had not been provided during 2024. During an interview on 12/05/24 at 10:58 a.m., When requested the NOC shifts training records, the DSD…

    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 · D2024-12-06 · 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

    Based on observation, interview, and record review, the facility failed to ensure baseline care plans (instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) were developed and implemented within 48 hours of admission for one (1) out of 21 sampled residents (Resident 238) when Resident 238 had been ordered anti-seizure medication without related seizure monitoring and care plan. This failure had the potential to place Resident 238 at risk for unmet care needs. Findings: A review of Resident 238's admission record indicated Resident 238 was admitted to the facility in November of 2024, with diagnoses including a fracture of the left femur (a thigh bone) and a fall with subsequent encounter (aftercare). A review of Resident 238's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for November and December of 2024 indicated order initiated on 11/19/24 for Divalproex Sodium 250 MG (milligram, unit of mass) two…

    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
Show the remaining 12 citations
  • Potential for harm · Dcited before2024-12-06 · 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

    Based on interview and record review the facility failed to provide services according to professional standards when anticoagulant (medications that prevent or reduce blood clotting) monitoring was not in place for Resident 63. This failure had the potential to put Resident 63 at risk for having complications related to excessive bleeding. Findings: A review of an admission record indicated Resident 63 was admitted to the facility in February 2023 with diagnoses including pulmonary embolism (blood clot in an artery in the lung), embolism and thrombosis of the left leg (a blood clot blocks or narrows an artery in the leg). During a review of Resident 63's, Medication Administration Record, on 12/4/24 at 10:04 a.m., the record indicated Resident 63 was receiving apixaban (medication that decreases the clotting ability of the blood) tablet twice a day. The record did not indicate an order to monitor side effects such as excessive bleeding or bruising. During a review of Resident 63's Care Plan, on 12/4/24 at 10:05 a.m., it did not indicate an anticoagulant monitoring care plan. During…

    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 · D2024-12-06 · 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

    Based on observation, interview, and record review, the facility failed to provide respiratory care services consistent with professional standards of care and facility policy, for one (1) resident (Resident 240), out of 21 sampled residents, when: 1. Resident 240's nasal cannula (NC- nasal cannula, special tubing that delivers gas to the nostrils) was unlabeled with a date it was changed; and 2. facility's orders and practices in changing humidifier bottle (a bottle of distilled water inserted into an oxygen delivery system to add moisture when being administered oxygen) and nasal cannula were not in agreement with facility's policy. These failures increased the risk for resident 240 to develop respiratory infections. Findings: A review of Resident 240's admission record indicated that Resident 240 was admitted to the facility in November of 2024 with diagnoses including respiratory failure with hypoxia (problems with breathing and low oxygen levels). A review of Resident 240's order summary report (OSR), dated 12/6/24, included the following active orders: O2 [oxygen gas] at 2…

    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 · D2024-12-06 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to develop a comprehensive dementia (a progressive state of decline in mental abilities) care plan for one out of 21 sampled residents (Resident 57), when there was no dementia care plan for Resident 57. This deficient practice had the potential to delay dementia treatments and services needed for Resident 57. Findings: A review of Resident 57's admission record indicated the resident was admitted to the facility in October 2024, with diagnoses that include senile degeneration of the brain (decline in cognitive function) and dementia. A review of Resident 57's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 10/18/24, indicated the resident has moderate cognitive impairment and non-Alzheimer's (a disease characterized by a progressive decline in mental abilities) dementia. During a concurrent interview and record review on 12/5/24 at 1:54 p.m., with Licensed Nurse 1 (LN 1), Resident 57's care plans were reviewed. LN 1 confirmed there was not a dementia care plan for Resident 57. LN 1 stated that…

    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 · D2024-09-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (Resident 1) of two sampled residents was free of abuse when Resident 2 slapped Resident 1 on the back. This failure resulted in an increase in Resident 1's potential for social withdrawal and fear for his safety. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in 2023 with diagnoses which included syncope (fainting) and collapse and dementia (a chronic condition which results in a decline in the person ' s ability to think, remember, and reason). A review of a Minimum Data Set (MDS, an assessment tool) dated 8/2/24 indicated Resident 1 had a score of 10 on a Brief Interview for Mental Status (BIMS, a questionnaire used to determine if a person's cognition (the process of thinking) is intact. A score of 15 suggests intact cognition). A review of an admission record indicated Resident 2 was admitted to the facility in 2022 with diagnoses which included orthopedic aftercare (care after…

    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 · Ecited before2024-04-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement guidance and recommendations to prevent the spread of Covid 19 infections to 18 out of 54 residents, Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, one (1) contractor and one (1) staff when: 1) The facility did not screen staff and visitors for any sign and symptoms of fever and cough before entering the facility. The staff, visitors and residents did not wear a N95 mask in the facility. The facility continued communal dining, activity, and physical therapy sessions. 2) The facility did not inform the Local Department Public Health in a timely manner when a Covid-19 outbreak, three (3) or more confirmed residents with Covid-19, occurred on 4/1/24. The facility reported the outbreak on 4/2/24. The facility did not inform the State Department of Public Health (CDPH) of the Covid-19 outbreak. 3) The facility did not screen residents and staff for Covid-19, who were exposed to Covid-19, as recommended by…

    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 · E2024-02-28 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report one incident of resident abuse to authorities within the required two-hour time frame after the allegation was made. This failure to report an allegation of abuse within the Federally mandated requirement of two hours, had the potential to result in ongoing resident abuse and physical, mental, and /or emotional harm, and prevented the State Agency from conducting a timely investigation into the allegation. Findings: Record Review of admission Record for Resident 1 indicated admission was on 12/13/23 and pertinent diagnoses are Other Specified Fracture of Unspecified Pubis, Subsequent Encounter for Fracture with Routine Healing and Anxiety Disorder Unspecified. During an interview on 2/20/24 at 12:14 p.m. with the Director of Nursing (DON), the DON stated Licensed Nurse A received an order for Resident 1 for a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) collection of urine for a urinalysis (a lab test of urine to determine the presence…

    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 · D2024-02-28 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to maintain documentation that an alleged abuse violation was thoroughly investigated. This failure to maintain documentation of an abuse investigation had the potential to delay implementation of corrective action(s) to protect the resident from further abuse and/or emotional harm. Findings: Record Review of admission Record for Resident 1 indicated admission was on 12/13/23 and pertinent diagnoses are Other Specified Fracture of Unspecified Pubis, Subsequent Encounter for Fracture with Routine Healing and Anxiety Disorder Unspecified. During an interview on 2/20/24 at 12:14 p.m. with the Director of Nursing (DON), the DON stated Licensed Nurse A received an order for Resident 1 for a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) collection of urine for a urinalysis (a lab test of urine to determine the presence of a urinary tract infection) on 12/27/23. During an interview on 2/20/24 at 12:30 p.m. with the Administrator, the Administrator 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-16 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 provide the Skilled Nursing Advanced Beneficiary Notice of Noncoverage (SNF-ABN, a notice provided to Medicare recipients informing them of the upcoming end of Medicare reimbursement for a particular medical service) to the responsible parties for two of three sampled residents (Residents 47 and 62) receiving Medicare Part A benefits, when facility stated they did not know the facility had to provide a SNF-ABN. This failure did not ensure resident rights to appeal the non-coverage determination and had the potential to expose each resident to unnecessary financial liability associated with receiving non-covered services (e.g., services not covered by Medicare Part A). Findings: RESIDENT 47 During a record review for Resident 47, the Face sheet (A one-page summary of important information about a resident) indicated Resident 47 was readmitted on [DATE], with diagnoses including Benign Neoplasm of Meninges (tumor that grows from the meninges, 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-16 · 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 and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool completed by clinical staff) was accurately completed for five of five sampled residents (Resident 4, 50, 8, 29, and 42) when Residents 4, 50, 8, 29, and 42 did not receive follow-up Pneumococcal vaccination as recommended by the Centers for Disease Control and Prevention (CDC) but the MDS for each resident indicated their Pneumococcal vaccination was up-to-date. This failure resulted to residents not getting the recommended Pneumococcal vaccine, putting each at-risk for increased respiratory infection. (Reference F883). Findings: RESIDENT 4 During a record review for Resident 4, the Immunization Record indicated Resident 4 received PCV13 (PneumoConjugate, a version of pneumococcal vaccine) on 3/27/2015. The Immunization Record indicated Resident 4 was past due for Pneumococcal 23, since 5/22/2015. During a record review for Resident 4, Section O0300 of the MDS, dated [DATE], indicated 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-16 · tag F0658 — failed to meet professional standards of care — pattern
    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 interview and record review, the facility failed to follow the physician's Protocol for Constipation for one of 5 sampled residents (Resident 280), causing Resident 280 to not have a bowel movement (BM) for eight days in a row. This had the potential for Resident 280's abdomen feeling full and bloated, and cause pain, hemorrhoids (swollen veins in your lower rectum) and unexplained weight loss, which could lead to Resident 280 being hospitalized . Findings: A review of Resident 280's admission Record, dated 12/15/22, indicated Resident 228 was admitted on [DATE], with a diagnosis including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), gastro-esophageal reflex disease (GERD, a chronic disease where stomach acid goes up into the esophagus (the muscular tube through which food passes from the throat to the stomach), causing inflammation and pain), dysphagia (swallowing difficulties), altered mental status, severe sepsis (infection causes…

    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 · E2022-12-16 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to offer the pneumococcal vaccine recommended by the Advisory Committee on Immunizations Practices (ACIP- provides advice and guidance to CDC [Centers for Disease Control] regarding use of vaccines and related agents for control of vaccine-preventable diseases) for five of five sampled residents (Resident 4, 50, 8, 29, and 42). This failure had the potential risk for residents to acquire and transmit pneumococcal bacteria that could result to serious respiratory infections. Findings: RESIDENT 4 During a record review for Resident 4, the Face sheet (A one-page summary of important information about a resident) indicated Resident 4 was admitted on [DATE] with diagnoses including Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Hypertension (High Blood Pressure) and Spondylosis (abnormal wear on the cartilage and bones of the neck). Resident 4 was [AGE] years old. During a record review for…

    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
  • No harm found · C2024-12-06 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews the facility failed to ensure complete nurse staffing data was displayed and accessible for residents and visitors, for a census of 82 residents, when actual hours worked was not displayed. This failure had the potential to mislead residents and visitors of the actual hours worked by staff responsible for providing direct care to residents. Findings: During an observation on 12/4/24 at 2:50 p.m. at the North Nursing station, the Daily Staffing form was displayed. The form included the number of Licensed Nurses (LN) and Certified Nursing Assistants (CNA) scheduled for each of the facility's shifts. However, the form did not include the actual hours worked by the LNs and CNAs, who are directly responsible for resident care. During a concurrent observation and interview on 12/4/24 at 3:20 p.m., at the North Nursing station, with the Medical Records Director (MRD), the MRD confirmed the Daily Staffing form displayed did not include the total number and actual hours worked per shift for LNs or CNAs. The MRD stated, I never thought I…

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

    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

$7,976 in federal fines across 1 penalty.

  • $7,976 — penalty dated 2024-02-06

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
VACAVILLE HEALTHCARE INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 05/16/2003
NICCOLI, JOSEPHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 05/16/2003
NICCOLI, SUSANIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 05/16/2003
CAYANAN, AIMILEEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/17/2006
VAN AKEN, TERRELLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/12/2025
JALEX LLCOrganizationADP OF THE SNFsince 06/01/2008
WIPFLI LLPOrganizationADP OF THE SNFsince 06/04/2021

CMS files one row per role, so the 16 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$18.2M
Net patient revenuemost recent cost report
+0.2%
Operating marginrevenue minus expenses
$1.4M
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 49%Medicare 21%Other / private 30%

This home reported $1.4M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$565per resident / day
operating cost
$17,176per month
≈ monthly operating cost
$566per 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 555349. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-06, 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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