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Springs Road Healthcare

1527 Springs Rd, Vallejo, CA 94591 · For profit - Corporation · 65 certified beds · (707) 643-2793 Medicare & Medicaid certified

Call the home — (707) 643-2793 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jul 2025
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (20% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

5/5
CMS overall
5 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 5 of 5

Location & what’s nearby

Hospital
Urgent care / clinic
96 Springstowne Ctr · (707) 642-4155 · Call to confirm hours
Pharmacy
Rite Aid0.1 mi
2021 Solano Ave · (707) 552-1476 · Call to confirm hours
Grocery
2107 Solano Ave · (707) 515-7995 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
50 Mariposa St · (707) 643-0820

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 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.4%10.2%15.4%better
Long-stay residents who lose too much weight7.4%4.0%5.4%worse
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 symptoms0.6%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 injury1.6%1.6%3.3%typical for the state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened9.5%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.8%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers4.7%4.3%4.7%typical
Long-stay residents with worsening bladder/bowel control2.0%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 table8.1%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 admission23.6%23.0%22.6%typical
Short-stay residents with an outpatient ER visit16.9%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.142.251.67better
Long-stay outpatient ER visits per 1,000 resident days3.341.571.80worse

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.

59.4% 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 114 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.4%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
53.1%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 53.1% 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 49 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNF59.4%CMS range 50.5–70.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.5–13.210.7%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 discharge53.1%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 discharge40.8%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 discharge49.0%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.6%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 hospitalization7.8%CMS range 4.3–13.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.50
RN hours/ resident / day
0.98
LPN hours/ resident / day
2.50
Aide hours/ resident / day
3.97
Total nurse hours/ resident / day
0.46
RN hoursweekends
19.7%
Total nursing turnover
12.5%
RN turnover

How full it usually is: this home is certified for 65 beds and averages 60.1 residents a day — about 92% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.50 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 3.65 hrs/resident/day on weekends vs 4.10 on weekdays — 11% thinner on weekends. RN hours go from 0.52 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 20% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2026-06-12)
5
at the previous standard inspection (2025-03-13)

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.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · Fcited before2026-06-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a census of 58 when:1. Dietary Supervisor (DS) and Dietary Aide (DA) 1 were not wearing a beard net while inside the kitchen.2. [NAME] residue was present on the floor surface of the food warmer.3. The top surface of the knife holder had accumulated dust and residue.4. Black residue was present on the floor beneath the dishwasher area.5. Three quarter size hotel pans were stacked wet while stored away.6. Flies were present in the kitchen area and dry storage area.7. Four lunch trays containing uncovered desserts were transported through the hallway.These failures had potential to cause food-borne illnesses in a highly susceptible population who received food from the kitchen.Findings:1. During an observation on 6/9/26 at 8:04 a.m. at the kitchen's initial tour, DS had a beard but was not wearing a beard net while in the kitchen 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-12 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    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 secure resident medical records containing Protected Health Information (PHI, any individually identifiable health information held, transmitted, or maintained by the health facility), for four Residents (Resident 11, Resident 39, Resident 59, and Resident 69) out of census of 58 residents, when the Treatment Nurse (TN) left printed wound treatment records on top of an unattended cart.This failure had the potential for unauthorized access by visitors, families, and other residents to Resident 11's, Resident 39's, Resident 59's, and Resident 69's medical records containing PHI.Findings: During an observation on 6/9/26 at 9:49 a.m. in the hallway outside of rooms 25 through 28 the TN left a paper stack of resident medical records unsecured on top of the treatment cart. Visitors, family members, and residents were observed walking past by the treatment cart within a viewing distance of the open, unsecured, and unprotected resident medical records. During a concurrent observation and interview on 6/9/26 at 9:53…

    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 · Ecited before2026-06-12 · 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 ensure services meet professional standards of quality for four residents (Resident 16, Resident 39, Resident 74, and Resident 6) for a census of 18, when:Medications were given without meals, as prescribed for Resident 16, Resident 39, and Resident 74;Medication with a box warning ((also known as black box warning- the strictest, most serious safety alert mandated by the U.S. Food and Drug Administration (FDA [a federal agency of the United States government responsible for protecting public health]) was being administered for Resident 6 without monitoring for side effects to highlight severe, life-threatening, or permanently disabling risks)).These failures had the potential to cause:Residents 16, Resident 39, and Resident 74 to have adverse side effects related to medications being administered without meals;Staff not monitoring Resident 6 for side effects related to taking medications with a box warning; Findings:1. A review of Resident 16's Face…

    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 before2026-06-12 · 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 medications were properly labeled and stored in accordance with the accepted professional principles and current standard of practice for Resident 33 and Resident 22 and for census of 58 when:1. Resident 33 was found to have medications at the bedside.2. An opened, unlabeled box of Lidocaine Patches 5% was found in the medication cart, containing one unopened packet and 2 opened packets; and3. Resident 22's white envelope containing twenty-five dollars in cash were found inside the narcotic box in medication cart.These failures had the potential for diversion of unlabeled medications and risk resident's safety. Stored personal valuables in the narcotic cabinet compromise the security of the controlled medications.1.Review of Resident 33's Face Sheet (a summary page in a resident's medical record that contains key identifying information about the resident) indicated that Resident 33 was admitted May of 2026 with several diagnoses including atherosclerotic heart disease (a condition where arteries…

    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 before2026-06-12 · 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 ensure proper infection control practices were implemented when: 1.Licensed Nurse (LN) 1 did not wear gown and gloves as indicated in Enhanced Barrier Precaution (EBP, an infection control intervention to reduce transmission of multi-drug-resistant organisms) guidance before entering the room and helped reposition Resident 9; 2. LN 3 took Resident 75's blood sugar and used disinfectant to clean the glucometers (hand-held devices that measure a person's blood glucose/sugar levels) that were not recommended by the manufacturer; Infection Preventionist (IP) B sanitized the glucometer using alcohol wipes before and after resident use; LN 3 stated she/he sanitized glucometer before and after resident use, using the alcohol wipes or the purple-top wipes (germicidal wipes); and, 3. Resident 48's nasal cannula was not stored in a bag. These failures had the potential to compromise resident's health and safety and potentially lead to the spread of…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop a communication/language barrier (an obstacle that prevents two or more people from understanding each other, that can lead to miscommunication) comprehensive care plan (CP- a personalized, written document that outlines how staff will manage a resident's medical, physical, and personal care needs daily) for one resident (Resident 6) out of 18 sampled residents, when there was no documented evidence of Resident 6's care plan addressing his preference to communicate in Spanish.This failure had the potential for miscommunication and misunderstanding when discussing medications, treatments, and care needs.Findings:A review of Resident 6's Face Sheet, indicated he was admitted to the facility on [DATE] and his preadmission document titled, [Resident initials] referral, uploaded to his chart on 5/6/26, indicated Resident 6 was Spanish speaking.During a concurrent observation and interview on 6/9/26 at 10:36 a.m., in the hallway outside…

    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 · Ddisputed · IDR2026-06-12 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure its medication error rate remained below five percent (5%) for two residents (Resident 25 and Resident 3) out of 18 sampled residents, when:Licensed Nurse (LN) 3 did not wear gloves when administering prescribed hazardous medication; and,LN 1 did not follow the physician's order when administering Resident 33's prescribed medications.These failures resulted in the facility's medication error rate of 6.45%, which had the potential for harm, worsening of existing conditions, or the development of new illnesses for Resident 25 and Resident 33.Findings:1. During a medication administration observation on 6/9/26 at 8:45 a.m., in Resident 25's room LN 3 did not wear gloves when dispensing the medication into a cup, and administering Topiramate (primarily used to treat and prevent seizures [epilepsy] and to prevent migraine headaches) tablet 100 mg (milligram, unit of measure) to Resident 25.A review of Resident 25's Order Summary Report (OSR) dated 2/21/25, indicated, Topiramate Tablet 100 MG Give 1.5 tablet…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1) Physician Orders for Life-Sustaining Treatment (POLST- a medical order that tells healthcare providers what treatments a patient wants or does not want, especially in serious illness or end-of-life care) was not implemented following the resident's return from the emergency room.This failure has resulted in Resident 1's POLST not implemented and reduced the facility's potential to provide necessary care and services to attain or maintain the resident's highest practicable wellbeing. Findings: During a review of Resident 1's admission record (AR- Front page of the chart that contains a summary of basic information about the resident), the AR indicated, Resident 1 was initially admitted to the facility 10/2018 with diagnoses including Acute Respiratory failure (a life threatening emergency where the lungs suddenly cannot get enough oxygen into the blood or remove carbon dioxide, often causing severe…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide professional standards of care for one of three sampled residents (Resident 1) when the x-ray (used to detect broken bones) order for Resident 1 was not carried out correctly.This failure resulted to an x-ray performed on Resident 1's right knee instead of the left knee. Resident 1's x-ray on the left knee indicated a fracture of the distal femur (a break in the thigh bone just above the knee joint) which required further evaluation and treatment in the acute care hospital.A review of the admission Record indicated Resident 1 was admitted April of 2023 with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy (long -term high blood sugar damages multiple nerves which leads to pain, tingling, burning, or numbness in the feet or hands) and weakness.A review of Resident 1's Brief Interview for Mental Status (BIMS- an assessment tool to screen and identify memory, orientation, and judgement status) dated 2/17/26 indicated Resident 1 was cognitively intact with a score of 14.A review of Resident 1'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure an allegation of abuse was reported timely within the required timeframe for two of four sampled residents (Resident 1 and Resident 2) when an allegation of abuse was not reported to the California Department of Public Health (CDPH).This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.During a review of Resident 1's admission record (AR), the AR indicated Resident 1 was admitted to the facility in June 2025 with multiple diagnoses including gastroenteritis (an inflammation of the stomach and intestines, causing symptoms like nausea, vomiting, diarrhea, abdominal cramps). During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility in December 2018 with multiple diagnosis including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During an interview on 7/11/25 at 11:59 a.m. with Resident 1, Resident 1 stated Resident 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · No revisit needed
Show the remaining 14 citations
  • Potential for harm · E2025-03-13 · tag F0550 — failed to protect resident dignity and rights — pattern
    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 record review, the facility failed to ensure four of 21 sampled residents (Residents 108, 53, 1, and 10) in a census of 61 privacy when curtains did not reach around personal space and vertical blind slats were missing. These failures resulted Resident 10 felt ashamed and increased the potential for increased feelings of reduced self esteem and embarrassment. Findings: Resident 108 was admitted to the facility in the winter of 2025 with diagnoses which included muscle weakness and difficulty walking. During a review of Resident 108's Minimum Data Set (MDS, an assessment tool), dated 3/4/25, the MDS indicated Resident 108 had moderate memory impairment. During a review of Resident 108's care plan (CP), titled Potential for alteration r/t [related to] .ADL support for .toileting ., dated 3/6/25, the CP indicated Provide privacy . During a concurrent observation and interview in a shared bedroom on 3/10/25 at 9:02 a.m., as Resident 108's curtains were being checked 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-13 · 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 accurately label medications for a census of 61 when: 1. Resident 54's insulin order was not reflected correctly on the medication label, and 2. The medications lacked resident labels and open dates, and the label was unclear and difficult to read. These failures had the potential for residents to receive the wrong medications, incorrect dosages of medications, and expired medications. Findings: 1. During a concurrent observation and interview on 3/11/25 at 8:55 a.m. during medication administration with Licensed Nurse ( LN 1), LN 1 administered 14 units (unit of measurement) of Humulin N (is an intermediate-acting insulin given to help control blood sugar levels in people with diabetes [a chronic condition that affects the way the body processes blood sugar]) 100Units/ml (milliliter, unit of measurement) to Resident 54. The resident's medication label both on the box, and the vial indicated inject 10 units . LN 1 verified in Resident 54's Medication Administration Record (MAR, document that serves as a legal…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-13 · 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

    Based on interview and record review, the facility failed to ensure an accurate inventory of narcotics (a medication that is used to relieve pain) for one of three sampled residents (Resident 35) when two tablets of narcotics were not entered into the residents Medication Administration Record (MAR, document that serves as a legal record of the drugs administered to a resident). This failure had the increased potential for drug diversion (when healthcare staff obtain and use prescription medicines illegally), and inaccurate monitoring of the amount and frequency of medications given to the resident. Findings: Resident 35 was admitted to the facility in 2019. Current principal diagnosis was acute respiratory failure (when the body does not get enough oxygen or there is too much carbon dioxide in the body). During a review of Resident 35's physician orders (PO) dated 3/13/25, the PO indicated, Percocet (oxycodone-acetaminophen, medications used to relieve pain) Oral Tablet 10-325 MG (milligram, unit of measurement, used for medication dosage and/or amount) Give 1 tablet .every 4 hours…

    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 · D2025-03-13 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 34) received a thorough monthly pharmacy medication regimen review (MRR). This failure placed Resident 34 at risk for receiving unnecessary, ineffective, and/or excessive dose of Lorazepam (a psychotropic medication to treat anxiety). Findings: Resident 34 was admitted to the facility with diagnoses including thickening and hardening of the walls of the arteries in the brain and anxiety disorder. Review of the admission MDS (Minimum Data Set, an assessment tool) indicated the resident scored 5/15 in the BIMS (Brief Interview for Mental Status, a cognitive assessment) which suggested he had severe cognitive impairment. Review of Resident 34's medical record indicated the resident had a physician order, dated 5/31/24, for Lorazepam 0.5 MG (milligram) to give 1 tablet by mouth every 6 hours as needed for anxiety for 14 day(s). There was no physician order to renew Lorazepam 0.5mg 14 days after the 5/31/24 order until 10/12/24. Review of the Medication Administration…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-13 · 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 ensure infection prevention and control program were maintained and to provide a sanitary environment when two lounge chairs in the dining/activity room were worn out, threadbare and available for resident use. This failure increased the risk for the transmission of communicable diseases. Findings: During an observation on 3/10/25 at 12:03 p.m., two large wing-back lounge chairs made of imitation leather were badly worn with mesh and foam showing through and available for use in the dining/activity room for use. Resident 51 was seen moving between and sitting in both lounge chairs. During a concurrent observation and interview on 3/10/25 at 12:05 p.m. with the Infection Preventionist (IP), the IP verified observation and stated, The lounge chairs used to be covered in leather. [The material] appears to be man made with the fabric lining and foam showing through. It can't be sanitized properly due to the mesh fabric. During an interview on 3/11/25 at 8:59 a.m. with the Director of Nurses (DON), the DON was…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-26 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the physician ' s order were followed to properly manage one out of two sampled resident's (Resident 1) pain. This failure resulted in inadequate pain management for Resident 1. Findings: A review of Resident 1 ' s face sheet (demographics) indicated an admission date of 11/3/24 to the facility. Resident 1 ' s diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). Resident 1 ' s Minimum Data Set (MDS, an assessment tool) dated 11/10/24 indicated intact cognition. A review of Resident 1 ' s pain monitoring on the electronic medical record (EMAR, an electronic health record that keeps track of when medications are given to the residents) for 11/2024 indicated Resident 1 complained of pain 26 out of 27 days since his admission on [DATE]. Resident 1 ' s EMAR for 11/2024 indicated an order for oxycodone (narcotic, analgesic) 5 milligram (mg, unit of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-26 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure there was an updated discharge plan for one out of two sampled residents (Resident 1) when: 1.There were no regular re-evaluation of Resident 1 to identify changes that require the modification his discharge plan. The discharge plan was not updated, as needed, to reflect these changes. 2.Resident 1 was not involved in the development of the discharge plan and was not informed of the final discharge plan. 3.There was no documentation that Resident 1 has been asked about his plans in returning to the community after he completed skilled services on 12/15/24. These failures to fully prepare Resident 1 be discharged for discharge from the facility could result to safety issues, prevent Resident 1 to be an active partner to effectively transition him to post-discharge care to prevent potential readmissions. Findings: A review of Resident 1 ' s face sheet (demographics) indicated an admission date of 11/3/24 to the facility. Resident 1 ' s diagnoses…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-26 · 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 interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) was safe during transfer when four certified nursing students were allowed to assist a staff member to transfer Resident 1 from his bed to the shower chair. This failure resulted to Resident 1 to fall on 11/15/24. Findings: A review of Resident 1 ' s face sheet (demographics) indicated an admission date of 11/3/24 to the facility. Resident 1 ' s diagnoses included Muscle Weakness, Chronic Pain (persistent pain that last for more than 3 months) and Hemiplegia (paralysis on one side of the body). Resident 1 ' s Brief Interview for Mental Status (BIMS, a screening tool used to assess a person's cognitive functioning) dated 11/10/24 score was 15 indicating intact cognition. A review of Resident 1 ' s Minimum Data Set (MDS, a health status screening and assessment tool used for all residents of long term care nursing facilities) assessment dated [DATE] indicated he had intact cognition and he needed…

    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 before2023-06-08 · 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 b. Review of the admission Record indicated, Resident 34 was admitted to the facility on [DATE], with diagnoses which included chronic pain syndrome. During a concurrent observation and interview with Resident 34 on 6/5/23 8:40 AM, a white oblong pill sitting on a plastic spoon was on a table next to Resident 34's bed. When asked about the pill, Resident 34 stated, That's my Percocet! (opiate/narcotic pain medication) and immediately picked up the pill, put it in his mouth, and swallowed it. Resident 34 stated the night shift nurse, Licensed Vocational Nurse 5 (LVN 5) brought him the Percocet a few hours prior. Resident 34 reported, Sometimes they watch me swallow the pills but sometimes they don't, and I can keep it for later. During a concurrent interview and record review with (LVN 2) on 6/5/23 at 9:44 AM, Resident 34's Medication Administration Record was reviewed. LVN 5 documented he administered Percocet to Resident 34 on 6/5/23 at 5:54 AM. Resident 34's Percocet supply was observed with LVN 2. LVN 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 · D2023-06-08 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for the care and maintenance of a PICC (Peripherally Inserted Central Catheter) (a long catheter that is inserted through the skin into a large vein just above the heart used for administering antibiotics or fluid) for one of 17 sampled residents (Resident 28). As a result of this failure, Resident 28 was at risk for infection and complications from his PICC. Findings: Review of the admission Record indicated, Resident 28 was admitted to the facility on [DATE], with diagnoses which included sepsis (blood infection) and pressure ulcers, and Resident 28 required intravenous (IV) antibiotics (medication given through a vein to treat infection). During a concurrent observation and interview with Resident 28 on 6/6/23 at 8 AM, Resident 28 stated he had a PICC for IV antibiotics, which were discontinued approximately two weeks prior. Resident 28 reported the hub (essential part of 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-08 · 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 ensure medications were in stock and available to administer, for one unsampled resident (Resident 250). As a result of this failure, Resident 250 was at risk for potential complications of not receiving medications timely. Findings: Review of the admission Record indicated Resident 250 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection and colonic polyps (abnormal growths in the lining of the colon). During an observation of medication pass with Licensed Vocational Nurse 2 (LVN 2) on 6/7/23 at 8:05 AM, LVN 2 prepared Resident 250's morning medications. LVN 2 confirmed she was administering five medications to Resident 250 during the medication pass. Review of Resident 250's medication orders on 6/7/23 at 12 PM, indicated Resident 250 should have received six medications during the medication pass. LVN 2 did not administer Colace 250 mg (milligram) gel capsule (an over-the-counter stool softener)…

    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 · D2023-06-08 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 food at an appetizing temperature for 3 of 17 sampled residents (Resident 9, Resident 28, Resident 100) and one unsampled resident (Resident 10). This failure resulted in residents' dissatisfaction with their meals and the potential to decrease the amount of food consumed by residents, therefore reducing nutritional support aiding in recovery from illness or injury. Findings: During an interview with Resident 100 on 6/5/23 at 8:30 AM, Resident 100 stated, food is cold .and they don't do anything about it. During an interview with Resident 9 on 6/8/23 at 7:33 AM, Resident 9 stated his food is always cold by the time he got to eat. During an observation with Food Service Manager 1 (FSM 1) on 6/8/23 at 7:35 AM, FSM 1 validated the temperature of Resident 9's breakfast following delivery to Resident 9's room. The waffle was 82 degrees, and the hot cereal was 93 degrees. During an observation on 6/8/23 at 7:45 AM, Resident 10's eggs were verified by FSM 1 to be 97.6 degrees on the food rack prior 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-08 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 keep the kitchen and equipment clean, free from residual food build up and grime. This failure resulted in unsanitary work areas where pathogens could potentially affect the residents with food-borne illness. Findings: During an observation on 6/8/23 at 7:05 AM, in the facility kitchen, many surfaces and equipment had the discoloration of food build-up and grime in various locations. Photographs were taken to capture the soilage. Areas noted were: An electrical socket located behind the toaster, the facial surface of the blender, the toaster, the steamer door, inside and out, the scale, a bracket fixated on the doorframe of the door to the parking lot, the dishwasher, signage, the can opener's base and the door frame to the food service office. During a concurrent interview and observation on 6/8/23 at 9:00 AM with Food Service Manager 1 (FSM 1), in the kitchen, the FSM 1 verified the presence of the discoloration from food build-up and grime at the various locations observed. The FSM 1 stated his staff should…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-08 · 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 interview and record review, the facility failed to provide evidence of annual tuberculin skin test (a test to determine the presence of infection with tuberculosis and bacterial infection of the lungs) results for Infection Preventionist 1(IP 1). This failure had the potential to spread undetected Tuberculosis (TB) infection (spread through the air from one person to another when a person with TB coughs and speaks) to a universe of 55 Residents in the facility. Findings: During a review of IP 1's personal file, indicated, Quantiferon-TB Gold Plus test (tests for TB infection) results were done on 3/20/22. During an interview with the Director of Staff Development (DSD) on 6/8/23 at 9:45 AM, the DSD confirmed the IP 1 did not have an updated purified protein derivative (PPD-to help diagnose tuberculosis infection) skin test for TB. During an interview with Director of Nursing (DON) on 6/8/23 at 10:39 AM, the DON stated the IP 1's tuberculin skin test should have been updated and done annually. The facility's policy and procedure, titled, Employee Tuberculosis Screening,…

    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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

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 BVHC, LLC — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 53.3+1.7 vs chain
Health inspection 4 of 53.0+1.0 vs chain
Staffing 4 of 53.4+0.6 vs chain
Quality measures 5 of 53.8+1.2 vs chain
The other 11 homes this chain runs (chain average 3.3★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
AIREY, CONNORIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2024
ANIERDES, PRINCES VALERIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2023
BALLESTEROS, FRANCIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2023
CALABAZARON, REDENTORIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/14/2022
DHUGGA, GURPREETIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
ESPINOZA, DESIREIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/18/2025
SECENA, EDGARIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2023
THAPA, NISCHALIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/06/2024

CMS files one row per role, so the 16 rows in the source record cover these 8 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.

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.

$8.1M
Net patient revenuemost recent cost report
+2.9%
Operating marginrevenue minus expenses
$491K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 68%Medicare 13%Other / private 18%

This home reported $491K 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

$435per resident / day
operating cost
$13,236per month
≈ monthly operating cost
$449per 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 055222. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-12, 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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