Delta Healthcare & Wellness Center, LP
514 North Bridge Street, Visalia, CA 93291 · For profit - Partnership · 44 certified beds · (559) 732-8614 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- 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 number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 1.5% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 4.0% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.4% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.9% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 0.0% | 9.8% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 26.0% | 13.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.7% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 2.4% | 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 table | 0.0% | 12.0% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.6% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.4% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 8.1% | 11.2% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
62.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 145 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.3% 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 75 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 0.56 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 62.4%CMS range 52.8–70.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 7.2–14.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 53.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 66.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 48.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 93.3% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.6%CMS range 3.9–10.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 44 beds and averages 39.7 residents a day — about 90% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.33 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.62 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.87 hrs/resident/day on weekends vs 4.51 on weekdays — 14% thinner on weekends. RN hours go from 0.34 to 0.29 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
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.
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.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · D2025-08-14 · tag F0573 — isolatedLet each resident or the resident's legal representative access or purchase copies of all the resident's records.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow its policy and procedure (P&P) when medical records were not provided to the responsible party (R/P) for one of 18 sampled residents (Resident 1) as requested. This failure resulted in Resident 1's R/P not being provided with Resident 1's medical records. Findings:During a review of Resident 1's Durable Power of Attorney (DPA) dated 8/18/12, the DPA indicated, I, (Resident 1).hereby appoint (Family Member 1) .as my attorney-in-fact ( Agent) to exercise the powers and discretions described below.My Agent's powers shall include, but not be limited to, the power to.have access to my healthcare and medical records and statements regarding billing, insurance and payments.During a review of Resident 1's Resident Request for Access to Protected Health Information (RRAPHI) dated 4/13/25, the RRAPHI indicated, (Resident 1).I would like to access and inspect my Protected Health Information (PHI) .I would like the facility to send a copy of my PHI to (FM1).I would like a summary of my requested PHI.Signature (FM 1).During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-14 · tag F0620 — isolatedNot require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
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 an itemized statement per the admission agreement to one of 18 sampled (Resident 1) residents when requested. This failure had the potential for Resident 1 to be unaware of services she was being billed for. Findings:During a review of Resident 1's monthly statements dated 5/31/25, 6/20/25, and 7/20/25, the monthly statements did not include an itemized billing.During an interview on 8/6/25 at 10:48 a.m. with Family Member (FM) 1, FM 1 stated he had requested an itemized bill from the facility and it had not been provided. During an interview on 8/6/25 at 1:42 p.m. with Administrator, Administrator stated FM 1 had requested an itemized bill indicating how much Resident 1 was being charged for each service. Administrator stated FM 1 was provided with a generic statement that did not indicate the individual service charge. Facility policy requested and none provided.During a review of the facility's California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities (CSAASNFICF)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-14 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to collaborate care with hospice (specialized form of medical care provided to individuals with terminal illness) for one of 18 sampled residents (Resident 1) when a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was identified to Resident 1's lower back by hospice, and the facility was unaware. This failure had the potential for Resident 1's pressure ulcer to go untreated and worsen.Findings:During a review of Resident 1's Hosp SN Visit (HSV-hospice documentation) dated 5/16/25, the HSV indicated, Integumentary (skin) Status.Wounds 1 lower back pressure ulcer/injury, stage 2-partial thickness skin loss of exposed dermis, observable, most problematic pressure ulcer/injury.cleanse with DWS (dermal wound spray-used to clean wounds) and pat dry. Apply hydrogel (medication used to promote healing) to wound bed and cover with pink Allevyn sacral dressing for extra padding. Change Mondays and Thursdays or PRN soiling/dislodgement.date first identified.5/16/25.During a review 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.
- Potential for harm · F2025-05-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure food items were used by the discard date, dated when opened, and labeled. This failure had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) to the residents. Findings: During a concurrent observation and interview on 5/12/25 at 9:01 a.m. with Certified Dietary Manager (CDM) in the kitchen, there was a large container with brown liquid that was not labeled. CDM stated it was iced tea, and it should be labeled. During a concurrent observation and interview on 5/12/25 at 9:03 a.m. with CDM in the kitchen, there were three pitchers of juice with no labels in the refrigerator. CDM stated there should be a label with the date of when the juice was poured into the pitchers. During a concurrent observation and interview on 5/12/25 at 9:05 a.m. with CDM in the kitchen, there were opened, unlabeled containers of mayonnaise and ranch dressing in the refrigerator. CDM stated the containers should be labeled with a date when opened. During a concurrent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-15 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 a medication error rate of less than five percent for two of five sampled residents (Resident 33 and Resident 6). This failure resulted in Resident 33 and Resident 6 receiving medications unsafely and had the potential for adverse outcomes. Findings: During an observation on 5/15/25 at 8:46 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 33's room. LVN 2 administered Lisinopril (used to treat high blood pressure, heart failure, and to improve survival after a heart attack) 5 milligrams (mg), Carvedilol (used to treat heart failure and high blood pressure) 3.125 mg, and Spironalactone (used to treat high blood pressure, heart failure, and fluid retention) 25 mg, by mouth to Resident 33. LVN 2 did not take Resident 33's heart rate or blood pressure before administering the medications. During an observation on 5/15/25 at 8:55 a.m. with LVN 2 in Resident 6's room, LVN 2 administered Amlodipine (used to treat high blood pressure and certain types of chest pain) 5 mg by mouth to Resident 6. 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.
- Potential for harm · E2025-05-15 · tag F0880 — failed to prevent and control infections — patternProvide 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 standards for two of eight residents (Resident 7 and Resident 21). This failure had the potential to spread illness to residents, staff, and visitors. Findings: During an observation and interview on 5/13/25 at 9:38 a.m. with Physical Therapist (PT) 1 in hallway, trash cans were not in the rooms and two were noted in the hallway. PT 1 exited Resident 7's isolation room with a soiled isolation gown rolled up in her hands. PT 1 crossed the hallway to dispose of the gown in the hallway trash can. PT 1 stated, There isn't a trash can in the room big enough for soiled personal protective equipment [PPE- gowns, gloves, and masks used to prevent the spread of infection]. During a concurrent observation and interview on 5/13/25 at 9:44 a.m. with Hospice Aide (HA), in Resident 21's room, which had transmission-based precautions (TBP-placed for residents who are documented or are suspected of having communicable diseases or infections that can be transmitted to others) signage and a PPE cart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-15 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 196), was assisted to the bathroom when she asked for help. This failure resulted in Resident 196 being frustrated and had the potential for increased incontinence (inability to control urination and/or bowel) and decreased mobility. Findings: During an interview on [DATE] at 12:20 p.m. with Resident 196, Resident 196 stated when she came back from her dialysis treatment yesterday, she asked the staff to help her go to the bathroom for a bowel movement. Resident 196 stated the staff told her to wait and poop in her pants and staff will change her afterwards. Resident 196 stated she felt frustrated, and she would have gone to the bathroom if she could. Resident 196 stated she just pooped in her diaper because she could not do anything. During a review of Resident 196's Care Plan Report (CPR), undated, the CPR indicated, Resident 196 was on a B&B (bowel and bladder) management program: Staff to offer and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-15 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure documentation of the Advance Directive (legal document outlining a person's healthcare and end of life wishes should the person become unable to verbalize those wishes) status was accurate for one of four sampled residents (Resident 10). This failure resulted in an inaccurate medical record and had the potential for Resident 10's healthcare wishes not to be honored. Findings: During a concurrent interview and record review on 5/14/25 at 10:48 a.m. with Social Services Director (SSD) 1 and SSD 2, Resident 10's medical record was reviewed. SSD 1 stated the Physician's Order for Life Sustaining Treatment (POLST) dated 1/20/20, indicated No Advance Directive. The Social Services Progress Notes dated 1/24/25 indicated, Advance Directive . a. Yes [has an advance directive] on file. SSD 1 stated she was unable to find a copy of Resident 10's advance directive. During a review of the facilities policy and procedure (P&P) titled, Advance Directive dated 7/31/24, the P&P indicated, Advance Directive Information . c. 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.
- Potential for harm · D2025-05-15 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to communicate a nurse-to-nurse report when transferring a resident to the hospital for one of two sampled residents (Resident 1). This failure resulted in the hospital not having any of Resident 1's medical or surgical history. Findings: During a concurrent interview and record review on 5/14/25 at 11:12 a.m. with Social Services Director (SSD) 1, Resident 1's Medical Record (MR) was reviewed. SSD 1 stated Resident 1 was transferred to the hospital for labored breathing. The Physician Order dated 4/12/25 at 11 a.m. indicated, send to ED [emergency department] for eval[uation] and treat as needed one time only for labored breathing for 1 Day. The SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form (HTF), dated 4/11/25, indicated, the form was completed and reviewed by Licensed Vocational Nurse (LVN) 4. The HTF indicated, Report Called in By (name/title) was filled in with na [not applicable] and Report Called in to (name/title) was filled in with na. During a concurrent interview and record review on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-15 · tag F0655 — isolatedCreate 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 one of one sampled resident (Resident 196), was administered oxygen according to physician's order. This failure had the potential to result in Resident 196 to experience hypoxia (low levels of oxygen in the body) or hyperoxia (high level of oxygen in the body). Findings: During a concurrent observation and interview on 5/12/25 at 10:03 a.m. with Resident 196 in her room, Resident 196's oxygen setting on the oxygen concentrator was 5 LPM (liters per minute). Resident 196 stated it was always at 3 LPM. During an interview on 5/12/25 at 12:41 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 196's oxygen setting order was 2 LPM. During a concurrent observation and interview on 5/12/25 at 12:42 p.m. with Certified Nursing Assistant (CNA) 1 in the Yellow Hallway, CNA 1 was wheeling Resident 196 with an oxygen tank behind the wheelchair. CNA 1 stated the oxygen was set at 2 LPM. Resident 196 told CNA 1 her oxygen was supposed to be at 3 LPM. During a review of Resident 196's Order Summary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · D2025-05-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 assess the skin of one of four sampled residents (Resident 31). This failure resulted in skin breakdown and pain for Resident 31. Findings: During an interview on 5/13/25 at 10:35 a.m. with Family Member (FM) 1, FM 1 stated Resident 31 was dependent on staff for positioning and repositioning in bed. FM 1 stated Resident 31 had arthritis which caused her a lot of pain. FM 1 stated Resident 31 would usually lay on her left side because it was less painful for her. FM 1 stated Resident 31 had sores and redness on her left ear, left outer ankle, left outer foot, and right inner foot. During a review of Resident 31's admission Record (AR) dated 12/22/22, the AR indicated Resident 31's diagnoses included, OTHER ABNORMALITIES OF GAIT [manner of walking] AND MOBILITY . MUSCLE WEAKNESS . DEAF NONSPEAKING . RHEUMATOID ARTHRITIS [body's immune system attacks the lining of the joints causing pain and swelling]. During a concurrent interview and record review on 5/14/25 at 3:45 p.m. with Social Services…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning for one of four sampled residents (Resident 10). This failure resulted in Resident 10 falling and sustaining a broken femoral neck (bone that connects upper leg to hip) bone. Findings: During a concurrent interview and record review on 5/14/25 at 10:02 a.m. with Social Services Director (SSD) 1 and SSD 2, Resident 10's Medical Record (MR) was reviewed. SSD 1 stated Resident 10 had an unwitnessed fall on 3/17/25 in her bathroom while attempting to self-toilet. Care Plan Report (CP), dated 2/13/25, indicated, Resident 10 was at risk for falls r/t [related to] impaired mobility and unsteadiness in gait [manner of walking]. The Physician Orders (PO), dated 3/17/25, at 11:15 a.m., indicated, Transfer to acute [hospital] for further evaluation related to Fracture [sic] of the left hip. The Discharge Documentation (DD), dated 3/22/25, indicated, Resident 10 was diagnosed with a Fracture [break] of femoral neck, left [side], requiring surgery…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-15 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
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 one sampled resident (Resident 196), post dialysis (mechanical removal of toxins in the blood when the kidneys no longer function adequately) access care was done timely. This failure had the potential for Resident 196's dialysis access to develop an infection or stenosis (narrowing of a vein or artery) which can cause prolonged bleeding and dialysis access failure. Findings: During a review of Resident 196's Order Summary Report (OSR), dated 5/13/25 the OSR indicated Resident 196 had an order to go to dialysis treatment every Monday, Wednesday, and Friday. During a concurrent observation and interview on 5/13/25 at 11:26 a.m. with Resident 196 in her room, Resident 196's dialysis dressing was on her left upper arm and asked Family Member (FM) 2 to take off the dressing. Resident 196 stated the staff was supposed to remove the dressing after her dialysis treatment on 5/12/25. During an interview on 5/15/25 at 12:14 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 196's dialysis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-08 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 services which meet professional standards of quality for one of 20 sampled residents (Resident 18) when Resident 18 was not administered oxygen (O2) per physician orders. This failure resulted in Resident 18 not receiving oxygen. Findings: During a concurrent observation and interview on 2/5/24 at 10:05 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 18's room, Resident 18 was lying down in bed and her nasal cannula (tube that goes in your nose and delivers oxygen) was in her nose. Upon checking the concentrator (machine that gives oxygen) the concentrator was off. LVN 1 stated Resident 18 should have continues oxygen on, and Resident 18's concentrator was off. During review of Resident 18's Order Summary Report (OSR) dated 2/6/2024, the OSR indicated, Oxygen 2 LPM [liter per minute] via nasal cannula every shift SOB [shortness of breath] R/T [Related to] every shift for SOB while in bed. During an interview on 2/6/24 at 2:28 p.m. with Director of Nursing (DON), DON stated expectation is 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.
- Potential for harm · Dcited before2024-02-08 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted. Findings: During an interview on 2/8/24 at 8:26 a.m. with Director of Nursing (DON), DON stated we have a RN who works on the weekends but does not work the full eight hours, or consistently works on the weekends. DON stated she has to come in a lot on the weekends especially on Sundays, and sometimes there is no coverage. During a concurrent interview and record review on 2/8/24 at 8:48 a.m. with Director of Staff Development (DSD), the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) dated 8/6/2023, 8/12/23, 8/13/23, 8/20/23, 9/3/23, 9/10/23, 9/16/23, 9/17/23, 9/30/23, 12/22/23, 12/24/23, and 12/30/23 were reviewed. DSD stated we have a weekend RN, but she does not come in on all weekends. DSD verified there was no RN on duty for the above dates.
- Potential for harm · D2024-02-08 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 remove expired medication from the medication cart. This failure had the potential to result in medications administered not to be effective. Findings: During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1, on 2/6/24 at 8:55 a.m. in the hallway at the green medication cart, the following expired medications were found in the cart: Artificial tear solutions (eye drops-lubricate dry eyes) opened on 10/25/23. Morphine Sulfate (Pain medication) liquid un-opened expired on 9/19/23. Hyoscyamine (Decrease acid production in the stomach) 0.125 mg (milligram-unit of measurement) tablet expired on 12/12/23. LVN 1 verified the findings. During an interview on 2/6/24 at 2:18 p.m. with Director of Nursing (DON), DON stated expectation is to audit cart every day and when nurses find expired medications in their cart, they turn in to me (DON). During a review of the facility's policy and procedure (P&P) titled, MEDICATION STORAGE IN THE FACILITY, dated 2014, the P&P indicated, Medications and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-08 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 appropriate use of an antibiotic (medication used to treat infection) for one of 20 sampled residents (Resident 99). This failure had the potential for unnecessary antibiotic usage leading to antibiotic resistant bacteria (Antimicrobial resistance happens when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them). Findings: During a concurrent interview and record review, on 2/7/24 at 10:17 a.m., with Infection Prevention Nurse (IPN), the facility's Infection Surveillance Monthly Report (ISMR), dated February 2024 was reviewed. The ISMR indicated Resident 99 had an onset date of 1/25/24, Infection: UTI (urinary tract infection), signs and symptoms: Dysuria (discomfort while urinating), Fatigue/Malaise (tiredness), New or marked increase in frequency, New or marked increase in urgency, Urinary complaints. IPN stated the resident, Resident 99, received the ordered medication Macrobid (antibiotic) as prescribed and completed the medication on 2/1/24. During a review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-08 · tag F0912 — isolatedProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
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 minimum square footage as required by regulation in 16 of the facility's resident bedrooms. This failure had the potential to provide insufficient space in the event of an actual emergency. Findings: During a concurrent interview and record review on 2/8/24 at 8:25 a.m. with Administrator, the facility's floor plan (FP) and facility census (FC) dated 2/5/24 was reviewed. The FP and FC indicated the following rooms did not provide the minimum square footage (sq. ft.) as required by regulation (80 sq. ft. per resident for multi occupation rooms). room [ROOM NUMBER]: 152 sq. ft. - two residents room [ROOM NUMBER]: 223 sq. ft. - three residents room [ROOM NUMBER]: 151 sq. ft. - two residents room [ROOM NUMBER]: 225 sq. ft. - three residents room [ROOM NUMBER]: 151 sq. ft. - two residents room [ROOM NUMBER]: 225 sq. ft. - three residents room [ROOM NUMBER]: 225 sq. ft. - three residents room [ROOM NUMBER]: 151 sq. ft. - two residents room [ROOM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-24 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to accurately complete Preadmission Screening and Resident Review (PASRR- Federal requirement to screen for mental illness and intellectual disabilities to ensure individuals are placed in nursing homes with appropriate services to meet their needs) Level I Screening, for five of 28 sampled residents (Resident 39, Resident 40, Resident 3, Resident 32, and Resident 28). This failure resulted in a Level II screening not being performed and had the potential for residents to be admitted to the facility without appropriate services available to them. Findings: During a review of Resident 39's PASRR, dated 11/12/21, the PASRR indicated, Section III- Serious Mental Illness Screen 10. Does the individual have a diagnosed mental disorder such as depression, Anxiety, Panic, Schizophrenia/Schizoaffective Disorder [mental disorder causing reality to be interpreted abnormally], Psychotic [disconnection from reality], Delusional [inability to differentiate something real from something imagined] and/or Mood Disorder [depression and/or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-03-24 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted. Findings: During a concurrent interview and record review, on 3/24/22, at 2:43 PM, with the Director of Nursing (DON), the facility's staff schedule titled, Nursing Schedule 2022 (NS), dated 3/22, was reviewed. The NS indicated, only Licensed Vocational Nurses (LVN) were scheduled. DON stated, she was the only RN in the facility and did not always work seven days a week. DON stated, she did not have a printed schedule for herself, and her contract indicated a Monday through Friday schedule, eight hours per day. During the survey entrance conference on 3/21/22, at 9:30 AM, the Administrator stated, the facility did not have any staffing waivers.
- Potential for harm · D2022-03-24 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain the dignity of one of 28 sampled residents (Resident 28), when Resident 28 was not assisted to the bathroom in time and had to urinate and had a bowel movements in his briefs (adult absorbent undergarments). This failure resulted in Resident 28 feeling embarrassed. Findings: During an interview on 3/21/22, at 12:50 PM, with Resident 28's wife (Family Member -FM) 1, FM 1 stated, Resident 28 could feel sensation to empty his bowel and bladder. FM 1 stated, Resident 28 will put on his call light to ask for assistance to the bathroom, but the facility staff do not assist him in time and then he (Resident 28) has to go in his diaper. FM 1 stated, when this happened, Resident 28 told her it made him feel embarrassed. During an interview and record review on 3/24/22, at 11:59 AM, with Director of Nursing (DON), Resident 28's medical record was reviewed. Resident 28's Clinical admission Evaluation (CAE), dated 2/15/22, the CAE indicated, Resident 28 was assessed on admission to be continent [able to sense and control…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-24 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure two of 28 sampled residents (Resident 3 and Resident 32) were informed of their Advance Directive (AD- written statement of a person's wishes regarding medical treatment and end of life decisions, made to ensure those wishes are carried out should the person become unable to communicate their wishes) options. This failure had the potential for residents end of life wishes to not be honored. Findings: During a concurrent interview and record review on 3/23/22, at 12:02 PM, with Director of Admissions (DA), Resident 32's Record of admission Authorization (RAA), dated 5/13/16 was reviewed. Question 11 of the RAA indicated, Advance Directives: I have been informed in writing of the facility's policy(ies) regarding implementation of medical directives, of my right to draw up a Living Will or other directive for medical treatment including a Durable Power of Attorney for Health Care Decisions and my right to refuse or accept medical treatment. Neither of the Yes or No response boxes were marked. DA verified, Resident 32'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.
- Potential for harm · D2022-03-24 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 the Minimum Data Set (MDS - resident assessment and care screening tool) discharge assessment was transmitted within the required time frame for one of one sampled resident (Resident 1). This failure had the potential to negatively affect the provision of necessary care and services for Resident 1. Findings: During a review of Resident 1's MDS - Discharge Assessment (MDS-DA), dated 10/9/21, Resident 1's MDS-DA indicated, Resident 1's admission date (entry date to the facility) was on 9/13/21 and Resident 1's assessment completion date was on 10/22/21. Resident 1's discharge date from the facility was 10/9/21. During an interview on 3/23/22, at 3 PM, with MDS Nurse (MDSN), MDSN stated, Resident 1's MDS-DA was submitted late, it should have been transmitted 14 days after completion date. MDSN stated, Yes, it is a tag. During a review of the Centers for Medicare and Medicaid Services [CMS - a federal agency within the United States Department of Health and Human Services that administers Medicare program & works in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its policy and procedure for fall prevention program for one of 28 sampled residents (Resident 31), who had incidents of repeated falls. This failure had the potential to result in additional falls with major injuries to Resident 31. Findings: During a concurrent observation and interview, on 3/24/22, at 7:34 AM, with Certified Nursing Assistant (CNA) 1, inside Resident 31's room, Resident 31 was observed sitting up on his wheelchair facing the foot of his bed. Resident 31's call light was laying on his bed, not within Resident 31's reach. A posted white paper on Resident 31's wall indicated, Call, don't fall. CNA 1 stated, Yes, [Resident 31's] call light was not within reach, the call light should be within [Resident 31's] reach so that [Resident 31] can call and safety can be provided. During a concurrent observation and interview, on 3/24/22, at 7:35 AM, with CNA 2, outside Resident 31's room, there was no star observed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure care was provided to maintain bowel and bladder continence (ability to sense and control elimination of urine and/or bowel) for one of 28 sampled residents (Resident 28), when Resident 28 was not assisted to the bathroom in time and had to urinate and/or have bowel movements in Resident 28's briefs (adult absorbent undergarments). This failure had the potential for Resident 28 to not maintain his level of continence. Findings: During an interview on 3/21/22, at 12:50 PM, with Resident 28's wife (Family Member -FM) 1, FM 1 stated, Resident 28 could feel sensation to empty his bowel and bladder. FM 1 stated, Resident 28 will put on his call light to ask for assistance to the bathroom, but the facility staff did not assist him in time and then he (Resident 28) has to go in his diaper. During an interview and record review, on 3/24/22, at 11:59 AM, with Director of Nursing (DON), Resident 28's medical record was reviewed. The Clinical admission Evaluation (CAE), dated 2/15/22, the CAE indicated, Resident 28 was assessed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its policy and procedure for Oxygen Administration for one of 28 sampled residents (Resident 89). This failure had a potential to result in Resident 89's hypoxia (low oxygen levels in the blood). Findings: During a concurrent observation and interview on 3/21/22, at 11:20 AM, inside Resident 89's room, Resident 89 was observed with a nasal cannula (a plastic tube placed into the nose used to deliver supplemental oxygen) in his nose while sitting on his wheelchair. Resident 89's oxygen concentrator's (a medical device that gives extra oxygen) humidifying jar (humidifier bottle - may be used to alleviate a sore, dry and/or bloody nose) was empty of water. Restorative Nursing Assistant (RNA) stated, the humidifying jar should not be empty of water. During a review of Resident 89's, admission Record (AR), [undated], Resident 89's AR indicated, Resident 89 was admitted to the facility on [DATE], with diagnoses including acute…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-24 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop/implement a policy for anticoagulant (medication used to prevent blood clots and to prevent stroke) use for two of 28 sampled residents (Resident 31 and Resident 90). This failure had the potential for Resident 31 and Resident 90 to experience unnoticed excessive bleeding and bruising. Findings: During a concurrent interview and record review on 3/23/22, at 9:21 AM, with Licensed Vocational Nurse (LVN) 1, Resident 31's Order Summary Report (OSR), dated 1/31/22 was reviewed. Resident 31's OSR indicated, Resident 31 was to receive Eliquis (anticoagulant medication) tablet 5 milligrams (mg- unit of measure) by mouth two times a day. LVN 1 stated, Resident 31 did not have monitoring for the use of Eliquis medication, we should be monitoring for bleeding or bruising, blood in the urine or in [Resident 31's] feces [stools]. If the signs and symptoms were not monitored, the resident may have excessive bleeding. During a review of Resident 31'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.
- Potential for harm · D2022-03-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 28 sampled residents (Resident 31), who received psychotropic medication (any drug that is capable of affecting mood, emotions and behavior) was adequately monitored, by failing to properly identify the specific targeted behavior for the use of Prozac (a medication used to treat depression). This failure had the potential for Resident 31 to experience adverse side effects related to psychotropic medication including sedation (drowsiness), dizziness, and may lead to falls and injuries. Findings: During a concurrent interview and record review, on 3/23/22, at 9:21 AM, with Licensed Vocational Nurse (LVN) 1, Resident 31's Order Summary Report (OSR), dated 2/1/22, was reviewed. Resident 31's OSR indicated, Resident 31 was ordered to receive Prozac capsule 40 milligrams (mg- unit of measure) one time a day for depression related to major depressive disorder manifested by sadness over loss of life roles. LVN 1 stated, Resident 31 had episodes…
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.
- No harm found · Bcited before2022-03-24 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the minimum square footage as required by regulation in 15 of the facility's resident bedrooms. This had the potential to provide insufficient space in the event of an actual emergency. Findings: During a concurrent general observation of the facility, interview, and record review, on 3/24/22, at 6:21 PM, with Administrator, the facility's floor plan (FP) was reviewed. The FP indicated the following rooms did not provide the minimum square footage (sq. ft.) as required by regulation (80 sq. ft. per resident for multi occupation rooms): room [ROOM NUMBER]: 152 sq. ft. - two residents room [ROOM NUMBER]: 223 sq. ft. - three residents room [ROOM NUMBER]: 151 sq. ft. - two residents room [ROOM NUMBER]: 225 sq. ft. - three residents room [ROOM NUMBER]: 151 sq. ft. - two residents room [ROOM NUMBER]: 225 sq. ft. - three residents room [ROOM NUMBER]: 151 sq. ft. - two residents room [ROOM NUMBER]: 225 sq. ft. - three residents room [ROOM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CORPORATE INTERFACE SERVICES — 40 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.5 | +2.5 vs chain |
| Health inspection | 4 of 5 | 2.4 | +1.6 vs chain |
| Staffing | 2 of 5 | 2.4 | -0.4 vs chain |
| Quality measures | 5 of 5 | 3.9 | +1.1 vs chain |
The other 39 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CORPORATE INTERFACE SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/18/2024 |
| ROCKPORT ADMINISTRATIVE SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2021 |
| GROSSMAN, STEPHEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2025 |
| MADRIGAL, DARIO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/20/2025 |
| DELTA WELLNESS GP, LLC | Organization | GENERAL PARTNERSHIP INTEREST | since 10/09/2020 |
| RECHNITZ, SHLOMO | Individual | LIMITED PARTNERSHIP INTEREST | since 10/09/2020 |
| ERETZ DELTA PROPERTIES | Organization | ADP OF THE SNF | since 10/30/2020 |
CMS files one row per role, so the 11 rows in the source record cover these 7 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.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $399K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555354. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.