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La Casa Via Transitional Care Center

1449 Ygnacio Valley Road, Walnut Creek, CA 94598 · For profit - Limited Liability company · 99 certified beds · (925) 939-5820 Medicare & Medicaid certified

Call the home — (925) 939-5820 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a strong health-inspection score (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 (31% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (25) — 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
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1399 Ygnacio Valley Rd · (925) 326-4040 · Call to confirm hours
Pharmacy
112 La Casa Via Ste 100 · (925) 939-6312 · Call to confirm hours
Grocery
2590 N Main St · (925) 933-2590 · Call to confirm hours
Park
1540 Marchbanks Dr · Typically dawn to dusk
Place of worship
1650 Ygnacio Valley Rd · (925) 939-7911

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

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

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.3%10.2%15.4%better
Long-stay residents who lose too much weight1.8%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.3%0.8%0.9%better
Long-stay residents with a urinary tract infection1.1%1.2%2.0%better
Long-stay residents with depressive symptoms0.5%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 injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened8.8%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.7%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers2.0%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control16.8%10.2%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table12.3%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission20.0%23.0%22.6%better
Short-stay residents with an outpatient ER visit7.0%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days2.062.251.67worse
Long-stay outpatient ER visits per 1,000 resident days0.791.571.80better

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

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

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

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

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

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

58.9% 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 365 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.9%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
63.5%U.S. median 56.6%
Met the expected recovery
0.49U.S. median 0.31
Therapy hours / resident / day
0.35hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 63.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 167 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 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF58.9%CMS range 54.4–63.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 7.5–13.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge63.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge64.1%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 discharge64.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.9%CMS range 3.8–9.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 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

0.83
RN hours/ resident / day
0.57
LPN hours/ resident / day
2.57
Aide hours/ resident / day
3.96
Total nurse hours/ resident / day
0.68
RN hoursweekends
30.8%
Total nursing turnover
29.4%
RN turnover

How full it usually is: this home is certified for 99 beds and averages 76.9 residents a day — about 78% occupied, or roughly 22 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.96 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.57 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 3.85 hrs/resident/day on weekends vs 4.01 on weekdays — 4% thinner on weekends. RN hours go from 0.88 to 0.68 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% 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

9
deficiencies at the latest standard inspection (2025-06-05)
8
at the previous standard inspection (2023-11-30)

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.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Fcited before2025-06-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure one of one ice machines was clean. This failure practice could be result in illnesses and infections. Findings: During a concurrent observation and interview on 6/2/25 at 12:10 p.m., with the Maintenance Supervisor (MS) and Dietary Supervisor (DS), who were present in the ice machine room, inside the ice machine tray was wiped with a clean, white wipe. There was black residue on the wipe after wiping the inside of the ice machine. The black residue was confirmed by MS and DS. DS stated he checks and cleans the machine every month for maintenance, and cleans the machine as needed, DS stated he is not cleaning the machine every day or every week routinely. The DS was able to show the monthly maintenance log only and stated that is the only log that he had. During an interview on 6/2/25 at 3:00 p.m. with DS, DS stated the ice machine needed to be checked and cleaned every day for the safety of the residents and staff. Review of the facility's policy and procedure Ice Machines and Ice Storage Chests, dated…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure one of two sample selected residents (Resident 52) was treated with dignity, when Resident 52's urine bag was not covered by a privacy bag. This deficient practice had the potential to result in Resident 52 feeling embarrassed, humiliated, or disrespected, which can negatively impact Resident 52's mental and emotional well-being. Findings: A review of Resident 52's admission Record indicated Resident 52 was admitted to the facility with multiple diagnosis including major depression and cognitive decline. During a concurrent observation and interview on 6/2/25 at 12:00 p.m. with Licensed Vocational Nurse (LVN) 3, in Resident 52's room, it was noticed Resident 52's urine bag was hanging from the bedside, facing the main door of the room, making it visible to visitors. LVN 3 stated the urine bags need to be covered by a privacy bag and should not visible because of resident privacy and dignity. During an interview on 06/03/25 at 10:19 a.m., with the Director of Nursing (DON), DON stated the facility does not have any…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · 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

    Based on interviews and record reviews, the facility did not revise the care plan for two of two sample selected residents (Resident 19 and 52) with new diagnoses, when Residents 19, and 52 were diagnosed with depression and staff did not develop a care plan for depression. This failure in practice had the potential to result in inadequate care and support, potentially worsening their mental health condition, experiencing emotional distress, social withdrawal, and other negative health outcomes, and compromise to their overall well-being and quality of life. Findings: A review of Resident 52's admission Record indicated Resident 52 had a diagnosis of major depression and cognitive decline. A review of Resident 19's admission Record indicated Resident 19 had a diagnosis of depression. During a concurrent interview and record review on 6/4/25 at 1:36 p.m. with Director of Nursing (DON), DON reviewed Resident 52 and 19's diagnoses, MDS, and care plans. DON confirmed Residents 52 and 19 were diagnosed with depression and did not find care plans for their depression. DON stated the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 necessary services to maintain good grooming to one of three sampled residents (Resident 50) when she did not receive nail care. This failure had the potential for development of skin injuries and infection for Resident 50. During a review of Resident 50's admission Record, undated, the admission Record indicated Resident 50 was admitted to the facility in March 2025 with diagnoses that included diabetes, dementia, and heart failure. During a review of Resident 50's Minimum Data Set (MDS, , a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 4/27/25, the MDS indicated Resident 50's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) was 7, indicating Severe cognitive impairment. The MDS also indicated Resident 50 was dependent on staff for activities of daily living (ADLs, are those…

    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 · D2025-06-05 · 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 observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 181) was monitored for side effects of divalproex sodium (Depakote -a mood stabilizing medication) which was given to Resident 181 in error. This failure exposed Resident 181 to potentially serious adverse effects. Findings: During a review of Resident 181's admission Record, printed on 6/3/25, the admission Record indicated Resident 181 was admitted to the facility in March 2025. During a review of Resident 181's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/28/25, indicated Resident 181 had a Brief Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 12 out of 15 indicating moderate cognitive impairment. The MDS also indicated, Resident 181 had multiple diagnoses that included, hip fracture and depression. The MDS…

    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 · D2025-06-05 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure that one of five sampled residents (Resident 181) was not given unnecessary psychoactive (controls mood and behavior) medication when Resident 181 was given divalproex sodium (Depakote, a mood stabilizer) without appropriate indications for use. This failure resulted in Resident 181 receiving psychoactive medication without actual psychiatric diagnoses and unnecessarily exposed her to serious adverse side effects. Findings: During a review of Resident 181's admission Record, printed on 6/3/25, the admission Record indicated Resident 181 was admitted to the facility in March 2025. During a review of Resident 181's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/28/25, indicated Resident 181 had a Brief Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 12 out of 15…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 181) was free from significant medication error when Resident 181 was administered divalproex sodium (Depakote, a psychoactive medication that controls mood and behavior) in error 30 times. This failure resulted in Resident 181 to receive psychoactive medication in error. This failure also exposed Resident 181 to serious health complications and/or jeopardized her safety. Findings: During a review of Resident 181's admission Record, printed on 6/3/25, the admission Record indicated Resident 181 was admitted to the facility in March 2025. During a review of Resident 181's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/28/25, indicated Resident 181 had a Brief Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 12 out of 15 indicating…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure proper labeling and storage of medication when the following was noted: 1. Two multi-dose insulin pens for Residents 228 and 40 had no open and beyond use date (BUD-the date after which a medication should not be used) label. 2. Thirteen expired nasal swabs were kept with ready to use medications in medication storage area. This failure had the potential to result in the Residents 228 and 40 receiving ineffective medication doses and Residents receiving abnormal nasal swab test results which could lead to more health issues. Findings: 1. During a concurrent observation and interview on [DATE] at 11:54 a.m., outside Resident 228 room on medication cart, with Registered Nurse (RN) 2, a Novolog FlexPen Subcutaneous Solution Pen Injector 100 unit/milliliter (ml) (Insulin Aspart-fast-acting insulin used to treat high blood sugar/diabetes) had a label with Resident 228's name but no open or BUD label on the pen. Resident 228 had a blood…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, facility did not ensure sanitary and comfortable rooms for two of two sample selected residents (Resident 61 and 52), when Resident 61 and 52's rooms (Room numbers 36 and 38) were not clean with brown spots on various surfaces, and the floors were sticky and had food particles scattered around. This failure in practice could have potentially resulted an environment conducive to the growth of bacteria, mold, and other harmful microorganisms resulting in infections and other health issues for residents, and emotional distress and discomfort, leading to a decline in mental health and overall satisfaction with the facility. Findings: A review of Resident 52's admission Record indicated Resident 52 was diagnosed with major depression and heart failure. A review of Resident 61's admission Record indicated Resident 61 was diagnosed with multiple sclerosis (chronic auto immune disease that affects the central nervous system, disrupting communication between the brain and the body, and leading to symptoms such as muscle weakness,…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-09 · tag F0624 — isolated
    Prepare residents for a safe transfer or discharge from the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure one of three sample selected residents (Resident 1) had a safe and orderly discharge from the facility, when the facility discharged Resident 1 to home without preparation and orientation to the discharge and did not provide complete discharge medication for Resident 1. This failure resulted in Resident 1 suffering from pain and did not have pain medication as ordered by the physician (MD). Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with multiple diagnoses including joint replacement surgery on left knee and chronic pain. During an interview on 4/5/24 at 11:17 a.m. with Resident 1, Resident 1 stated she was at the facility for one day and the facility discharged her home without giving her pain medication for home use as ordered by MD. Resident 1 stated she suffered from too much pain and the next day staff from the facility picked up Resident 1's pain medication from the pharmacy and dropped it off at her house. Furthermore, Resident 1 stated the discharge…

    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
Show the remaining 15 citations
  • Potential for harm · D2024-04-09 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services for hygiene and bathing for one of three sample selected residents (Resident 1) when Resident 1 did not receive a shower as scheduled by the facility. This failure resulted in Resident 1 being uncomfortable and complained about not receiving the services that she was supposed to receive from the facility. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility, located at room [ROOM NUMBER] A with multiple diagnoses including joint replacement surgery on left knee and chronic pain. During an interview on 4/5/24 at 11:17 a.m., with Resident 1, Resident 1 stated the facility's staff did not give her a shower while she resided at the facility. She felt uncomfortable and needed to take a shower. During a concurrent interview and record review on 4/9/24 at 2:00 p.m. with the Clinical Manager (CM), CM reviewed the Activities of Daily Living (ADL)'s documents and confirmed that Resident 1…

    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 · E2023-11-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for two of 31 sample selected residents (Residents 10 and 11), when: 1. Resident 11 did not receive the oxygen rate based on physician order. 2. Resident 10's oxygen tube was not replaced weekly and the oxygen's humidifier was not replaced when it was empty. These deficient practices had the potential to result in oxygen toxicity for Resident 11 and for Resident 10 to potentially develop respiratory complications. Findings: 1. A review of Resident 11's admission Record indicated, Resident 11 was admitted to the facility with a diagnosis of interstitial pulmonary disease (broad term for a collection of over 150 disorders that inflame or scar the lungs). A review of Resident 11's Minimum Data Set (MDS-an assessment tool used to guide care) section I, indicated Resident 11 was admitted to the facility with a diagnosis of respiratory disease. A review of Resident 11'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 · E2023-11-30 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow posted menu when: 1. On 11/28/23, during lunch meal: - Pot stickers were not served as a garnish according to the menu. - Salad plates were provided which was not on the menu. 2. Resident 47 and Resident 140 stated menu was not routinely followed as listed. These failures had the potential for served meals to not meet the nutritional needs of the residents who received food from the kitchen. Findings: 1. During a concurrent interview and record review on 11/28/23, at 9:45 a.m., with the Food Services Director (FSD), facility's undated dietary document Fall Menu Week 3, was reviewed. The menu followed for 11/28/23, Tuesday, lunch meal showed teriyaki chicken, sauteed tofu (instead of vegetable chicken teriyaki), fried rice, garlic broccoli, pot sticker, and mandarin gelatin. During a concurrent observation and interview on 11/28/23, at 12:45 p.m. (after completion of tray line), with [NAME] 2 and FSD, residents were not served pot…

    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 · E2023-11-30 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 prepare pureed (cooked food that has been ground, pressed, and blended to a consistency of creamy paste) food designed to meet the needs of residents with a specialized diet. This failure had the potential to result in aspiration and choking (inhaling of food and drinks) of medically compromised residents who received pureed food from the kitchen. Findings: During a concurrent observation and interview on 11/28/23, at 12:15 p.m., pureed foods prepared by [NAME] 2 were on the kitchen steam table. [NAME] 2 stated he pureed the chicken teriyaki, broccoli, and rice separately by mixing water and thickener to the foods. During a concurrent observation and interviews on 11/28/23, at 12:45 p.m., with [NAME] 2 and Food Services Director (FSD), in front of the kitchen steam table, pureed chicken teriyaki, pureed broccoli, and pureed rice were scooped to the dinner plate and were observed runny in consistency. FSD checked the pureed food consistency by sticking a spoon upright in the center of each tray with pureed…

    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 · Ecited before2023-11-30 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. In the kitchen pantry, multiple opened gallon containers of liquid condiments did not have opened dates. 2. Freezer 1 contained three sealed boxes of meat stored without labels. 3. A dietary staff entered the kitchen without a hairnet. 4. Ice machine interior was unclean. 5. Ice Machine Room door was left open and accessible to unauthorized persons. 6. Resident Food Refrigerator inside Station 1 Medication Room was not cleaned routinely and freezer compartment at Station 1, had ice build-up. These failures had the potential to result in food contamination and resident foodborne illnesses. Findings: 1. During a concurrent observation and interview on 11/27/23, at 9:30 a.m., with the Food Services Director (FSD): Inside the Dry Storage Room, an opened gallon container of light unsulfured molasses had no open date. In the kitchen prep area, there were opened gallon containers of liquid condiments that were used and unlabeled with opened dates: -…

    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 · Ecited before2023-11-30 · 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

    Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident 234) of 31 sample selected residents when Registered Nurse (RN) 1 did not follow infection control standards during wound care for Resident 234. This failure had the potential to result in wound complications and infection for Resident 234. Findings: A review of Resident 234's admission Record indicated Resident 234 was admitted to the facility with a diagnosis of cellulitis (a bacterial infection) of the left lower limb. A review of Resident 234's physician orders for wound care, dated 11/23/23, indicated . R (right) elbow stage III (3) cleanse with NS (Normal Saline), pat dry, apply skin prep . During a concurrent observation and interview on 11/28/23, at 9:15 a.m., RN 1 was observed during the wound treatment for Resident 234 and these following issues were found: 1. RN 1 removed…

    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 · D2023-11-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure one of four sampled resident (Resident 70) on an antipsychotic (medication that treats several kinds of mental health conditions) was free from unnecessary drugs when the interdisciplinary team did not evaluate Resident 20's use of a PRN (as needed) for Seroquel's (antipsychotic) appropriateness, adequate clinical rational and indication for continued usage. This failure had the potential for Resident 70 to receive unnecessary drugs and suffer adverse medication side effects. Findings: During an observation and interview on 11/27/23 at 11:00 a.m., Resident 70 was sitting up in bed and stated being anxious and gets frustrated because she was helpless. To call for help, Resident 70 stated she screams out for help. Resident 1 stated she wanted someone to get her cell phone to be able to call and speak to her family. Review of the quarterly Minimum Data Set (MDS - an assessment screening tool used to guide care) dated 10/25/23 indicated Resident 70's Basic Interview of mental status (BIMS) score was 3…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-11-04 · 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

    Based on observation, interview, and record review, the facility failed to protect the right of privacy of confidential information for three of 28 sampled residents (Residents 73B, 50, 19) when personal care instructions were posted on the walls of the residents' shared rooms. These failures had the potential to result in emotional distress for Residents 19, 50, and 73B from public disclosure of personal information. Findings: During an observation on 11/3/21, at 9:02 a.m., in Resident 73B's room, an uncovered sign was posted on the wall across from Resident 73B's bed. The sign indicated Resident 73B required Swallowing Precautions. The sign listed specific information which included: supervision/assistance during meals, small sips, swallow before next bite. During an observation on 11/3/21, at 9:06 a.m., in the room shared by Resident 50 and Resident 19, there were uncovered signs with clinical and personal care instructions posted on the wall. The sign on the wall by Resident 50 indicated Resident 50 needed a soft diet and thin liquids, and Please make sure pt [patient] is: 1)…

    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 before2021-11-04 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served under sanitary conditions when: 1. Refrigerator 1 had multiple undated food items and repackaged food in plastic bags labeled with use-by dates more than three days in the future. 2. Refrigerator 2 had a cracked pasteurized egg left inside the refrigerator and an open carton of liquid whole eggs without an opened-on date. 3. Refrigerator 3 had a sealed bag of mixed green lettuce that had no label or use-by date. 4. Undated and unlabeled food items were stored in a large clear container. 5. The holder for the can opener in the kitchen work area was covered with brownish-yellow-colored sticky material around the can opener rest. These failures had the potential for residents to develop food-borne illness. Findings: During the initial kitchen tour observation on 11/1/21, at 10:10 a.m., with the Registered Dietitian (RD) and [NAME] 1: 1. Refrigerator 1 had the following items: a. A box of thawed, undated, turkey breakfast sausage links (15 pieces). b. Repackaged…

    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 · Ecited before2021-11-04 · 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

    Based on observation, interview, and record review, the facility failed to: 1. Clean the area around the enteral feeding pump (a pump used to deliver liquid nutrition directly into the stomach or intestines through a tube inserted into the nose, mouth, or a surgical opening directly into the gastrointestinal tract) for one (Resident 62) of 18 sampled residents. 2. Clean a resident walker stored in a common hallway. 3. Clean a bedside commode stored in a common hallway. These failures had the potential to result in infection and/or the spread of infection for Resident 62, and other residents and visitors in the facility. Findings: 1. A review of Resident 62's admission Record, undated, indicated Resident 62 was admitted in 2019 with a diagnosis of traumatic brain injury and a gastrostomy tube (a tube placed in a surgical opening created through the abdominal wall into the stomach to allow for direct infusion of nutrients and liquids). During an observation on 11/1/21 at 10:38 a.m., in Resident 62's room, an enteral feeding pump was attached to an IV pole (a pole on casters used for…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 maintenance services to maintain a clean, orderly, and comfortable environment for two of 28 sampled residents (Resident 50 and Resident 19) when: 1. Resident 50's dresser had no top drawer. 2. Resident 19's floor had multiple scattered black scratches and dimples on the surface of the floor and next to the resident's bed were sticky, brown-colored spots on the floor. This failure had the potential to decrease the comfort and well-being of Resident 50 and Resident 19. Findings: 1. During an observation on 11/1/21, at 11:09 a.m., Resident 50's dresser had an empty area where the top drawer of the dresser should have been located. The contents of the second dresser drawer were visible through the empty area. During a concurrent observation and interview (LVN 1) on 11/2/21, at 8:40 a.m., with Licensed Vocational Nurse 1, in Resident 50's room, LVN 1 stated the top drawer had been missing for quite a while. LVN 1 stated she did not know if anyone had reported that the top drawer was missing. LVN 1 stated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-04 · 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 interview and record review, the facility failed to act upon an irregularity identified by the Consultant Pharmacist (CP) during the monthly medication regimen review (MRR) for one of 28 sampled residents (Residents 50) when the facility delayed scheduling Resident 50's Abnormal Involuntary Movement Scale test (AIMS, a 12-item clinician rated scale of involuntary movements of various areas of the patient's body) for one month. This failure had the potential to result in Resident 50 having undiagnosed and untreated adverse side effects from prescribed medication use. Findings: A review of Resident 50's admission Record, undated, indicated Resident 50 was admitted to the facility in December 2020, with a diagnosis of dementia (a chronic progressive disease marked by memory loss, personality changes and impaired reasoning) with behavioral disturbance, and a mental condition causing disorientation to reality. A review of Resident 50's Order Summary Report, dated 11/3/21, the Order Summary Report indicated a physician order dated 8/23/21, for quetiapine (An antipsychotic…

    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 · D2021-11-04 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to offer and/or provide pneumococcal vaccine (a vaccination to prevent pneumonia, a lung infection which can cause difficulty breathing and death) to one (Resident 3) of five sampled residents. This failure had the potential for Resident 3 to develop and spread pneumonia. Findings: A review of Resident 3's admission Record, undated, indicated Resident 3 was admitted in 2014. During a concurrent interview and record review on 11/3/2021 at 8:35 a.m. with the Infection Preventionist (IP), Resident 3's Immunization record was reviewed. The IP stated Resident 3 last received a pneumococcal vaccine, Pneumovax (generic name of PPSV23) on 9/19/2014. The IP stated Resident 3 had not received another pneumococcal vaccination. The IP stated Resident 3 should have been given the pneumococcal vaccine 5 years after the last dose, unless Resident 3 wanted to refuse the vaccination. The IP stated she had not asked Resident 3 if she wanted a second…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-11-30 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 for one (Resident 14) of eight sampled residents, the quarterly minimum data set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) assessment was completed within the deadline determined by the assessment reference date (ARD, an endpoint for observation periods for MDS assessment data entry). This failure had the potential to delay Resident 14's individualized care. Findings: Resident 14 was admitted to the facility in 2023 with diagnoses of right sided hemiplegia (loss of muscle function on one side of the body) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) following a cerebral hemorrhage (bleed in the brain). During a concurrent interview and record review on 11/30/23, at 9:16 a.m., with the Director of Nursing (DON), Resident 14's quarterly MDS assessment, with an ARD of 11/10/23, was reviewed. The MDS assessment indicated it was not completed at the time of interview.…

    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
  • No harm found · B2023-11-30 · tag F0640 — pattern
    Encode 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for three (Residents 14, 67, 36) of eight sampled residents, the minimum data set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) assessments were submitted to the Centers for Medicare and Medicaid Services (CMS) within the deadlines determined by the assessment reference date (ARD, an endpoint for observation periods for MDS assessment data entry) when, 1. Resident 14's quarterly MDS assessment was not completed and transmitted, 2. Resident 67's discharge assessment was not completed and transmitted, and 3. Resident 36's discharge assessment was completed 26 calendar days past the ARD and not transmitted. These failures had the potential to delay Resident 14's individualized care and resulted in Resident 67 and 36's incomplete medical record. Findings: Resident 14 was admitted to the facility in 2023 with diagnoses of right sided hemiplegia (loss of muscle function…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ASPEN SKILLED HEALTHCARE — 35 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 53.7+1.3 vs chain
Health inspection 4 of 53.1+0.9 vs chain
Staffing 4 of 53.9+0.1 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 34 homes this chain runs (chain average 3.7★, per CMS)
1 of 5Kei-Ai Los Angeles Healthcare CenterLos Angeles, CA 2 of 5Berkley East Healthcare CenterSanta Monica, CA 2 of 5Bixby Towers Post-Acute RehabLong Beach, CA 2 of 5Ocean Pointe Healthcare CenterSanta Monica, CA 2 of 5Woodland Post-AcuteWoodland, CA 3 of 5Berkley Post-AcuteVan Nuys, CA 3 of 5Berkley West Healthcare CenterSanta Monica, CA 3 of 5Kei-Ai South Bay Healthcare CenterGardena, CA 3 of 5Lake Park Healthcare CenterOakland, CA 3 of 5Marina Pointe Healthcare & SubacuteCulver City, CA 3 of 5Mission Palms Healthcare CenterWestminster, CA 3 of 5Riverwood Health CareStockton, CA 3 of 5Sierra Vista HealthcareFresno, CA 3 of 5The Gardens Healthcare CenterNorthridge, CA 3 of 5Tracy Nursing And Rehabilitation CenterTracy, CA 4 of 5Alta Healthcare Center of CamarilloCamarillo, CA 4 of 5Country Crest Post-AcuteOroville, CA 4 of 5Lodi Nursing & RehabilitationLodi, CA 4 of 5North Park Post-AcuteTracy, CA 4 of 5San Juan Hills Healthcare CenterSan Juan Capistrano, CA 4 of 5South Marin Health & Wellness CenterGreenbrae, CA 4 of 5The Rehabilitation Center At The PalazzoPhoenix, AZ 4 of 5Villa Valencia Healthcare CenterLaguna Hills, CA 5 of 5Cottonwood Healthcare CenterWoodland, CA 5 of 5Greenridge Post AcuteEl Sobrante, CA 5 of 5Hillcrest Heights Healthcare CenterSan Diego, CA 5 of 5Oakland Heights Nursing And RehabilitationOakland, CA 5 of 5Pacific Heights Transitional Care CenterSan Francisco, CA 5 of 5Petaluma Post-Acute RehabilitationPetaluma, CA 5 of 5Stonebrook Health And RehabilitationLos Gatos, CA 5 of 5The Avenues Transitional Care CenterSan Francisco, CA 5 of 5The Springs Healthcare Center At The CarlottaPalm Desert, CA 5 of 5University Post-Acute RehabSacramento, CA 5 of 5Woodlands Healthcare CenterLos Gatos, CA

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

Who owns this facility

Owner / managerTypeRoleSince
AWCY LLCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/05/2019
ASPEN SKILLED HEALTHCARE INCOrganizationINDIRECT OWNERSHIP INTERESTsince 03/05/2019
SEQUOIA HEALTHCARE GROUP LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2023
SKBM LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 03/05/2019
BRADSHAW, JEFFREYIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2023
BRADSHAW, PETERIndividualINDIRECT OWNERSHIP INTERESTsince 07/07/2023
ELSNER, ERICIndividualINDIRECT OWNERSHIP INTERESTsince 03/05/2019
KIRKWOOD, JAREDIndividualINDIRECT OWNERSHIP INTERESTsince 03/05/2019
ORGILL, CRAIGIndividualINDIRECT OWNERSHIP INTERESTsince 03/05/2019
PARTI, RAJESHIndividualINDIRECT OWNERSHIP INTERESTsince 03/05/2019
PARTI, SHRUTYIndividualINDIRECT OWNERSHIP INTERESTsince 03/05/2019
PAXMAN, MARCUSIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2023
RAWE, COLTONIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
DAVIS, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2017
DHALIWAL, TANVEERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2021
SHAIKH, ZAHIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2017
ASPEN HEALTHCARE SERVICES LLCOrganizationADP OF THE SNFsince 01/01/2023
EAST WEST BANKOrganizationADP OF THE SNFsince 03/05/2019
MOSS ADAMS LLPOrganizationADP OF THE SNFsince 03/05/2019
WELLS FARGO BANK, NATIONAL ASSOCIATIONOrganizationADP OF THE SNFsince 03/05/2019
BRADY, VERNIndividualADP OF THE SNFsince 01/01/2023
CASE, RYANIndividualADP OF THE SNFsince 01/01/2023
JURADO, FRANKIndividualADP OF THE SNFsince 01/01/2023

CMS files one row per role, so the 34 rows in the source record cover these 23 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.

8 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.

$16.6M
Net patient revenuemost recent cost report
+12.2%
Operating marginrevenue minus expenses
$997K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 58%Medicare 23%Other / private 18%

This home reported $997K 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

$515per resident / day
operating cost
$15,666per month
≈ monthly operating cost
$587per 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 056399. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, 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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