Tice Valley Post Acute
1975 Tice Valley Blvd., Walnut Creek, CA 94595 · For profit - Limited Liability company · 120 certified beds · (925) 906-0200 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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)
- it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2023
- a high number of inspection citations overall (28) — 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.
| 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
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 | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 4.1% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.8% | 4.0% | 5.4% | better |
| 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 | 0.3% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.7% | 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 | 1.7% | 1.6% | 3.3% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 9.8% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.3% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.5% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 10.3% | 10.2% | 21.2% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.8% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.0% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.0% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.84 | 2.25 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.63 | 1.57 | 1.80 | typical |
‡ 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.
66.6% 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 135 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 74.8% 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 127 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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 | 66.6%CMS range 56.4–75.5 | 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 | 11.0%CMS range 8.5–14.8 | 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 | 74.8% | 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 | 65.3% | 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 | 56.7% | 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 | 100.0% | 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 | 100.0% | 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 | 0.4% | 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 | 7.2%CMS range 4.6–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 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 120 beds and averages 116.5 residents a day — about 97% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.25 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.37 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.78 hrs/resident/day on weekends vs 4.44 on weekdays — 15% thinner on weekends. RN hours go from 0.68 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%. 1 administrator has left in the past year.
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 unchanged from the previous inspection. 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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Fcited before2026-06-17 · tag F0836 — widespreadEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
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 state Title 22 regulations and ensure the social services department was staffed and supervised by qualified and competent staff which affect all 123 residents.This failure resulted in all 123 residents receiving social services care from unqualified staff. During an interview on 9/23/25, at 10:35 a.m., with Social Services Director (SSD), SSD stated they were the director of the social services department and were responsible for admission assessments, discharge planning. SSD stated the social services department assisted residents with dental, optometry, podiatry and psychiatric appointments to ensure residents' physical, mental and psychosocial needs were met. SSD stated they had been working since 5/2025.During a concurrent interview and record review on 9/24/25, at 4:23 p.m., with Director of Staff Development (DSD), SSD's two job descriptions, dated 5/15/25 and 8/18/25, were reviewed. DSD stated after review of the job descriptions, SSD did not meet the qualifications of the 5/25/25 description and did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-06-17 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for residents 1-8, the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered).2. The facility failed to ensure, between 2/1/24-6/30/24, the Consultant Pharmacist identified the scheduled (controlled medication, narcotic) medication system was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide services to maintain grooming and personal hygiene for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNAs) did not provide Resident 1 showers as scheduled by the facility. This failure placed Resident 1 at risk for poor hygiene, body odor, infection, and transmission of diseases. During a review of Resident 1's admission Record (AR), printed 3/25/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease and dependence on renal dialysis (Kidney failure impossible to service without dialysis). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 2/18/26, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation,…
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 · Fcited before2025-12-11 · tag F0836 — widespreadEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
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 state Title 22 regulations and ensure the social services department was staffed and supervised by qualified and competent staff which affected all 120 residents.This failure resulted in all 120 residents receiving social services care from unqualified staff.During an interview on 9/23/25, at 10:35 a.m., with Social Services Director (SSD), SSD stated they were the director of the social services department and were responsible for admission assessments, discharge planning. SSD stated the social services department assisted residents with dental, optometry, podiatry and psychiatric appointments to ensure residents' physical, mental and psychosocial needs were met. SSD stated they had been working since 5/2025.During a concurrent interview and record review on 9/24/25, at 4:23 p.m., with Director of Staff Development (DSD), SSD's two job descriptions, dated 5/15/25 and 8/18/25, were reviewed. DSD stated after review of the job descriptions, SSD did not meet the qualifications of the 5/25/25 description and did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and medical record and document review, the facility failed to provide services for activities of daily living for 1 (Resident 50) of 8 sampled residents when: For Resident 50, fingernails were long and had black debris under the fingernails. These failures resulted in resident not having their hygiene maintained and had the potential to increase risk for infection. Findings:During an observation on 9/23/25, at 10:35 a.m., Resident 50 sat in bed and ate yogurt. Resident 50 stated she could feed herself. Resident 50 had black debris under her fingernails to both hands. Resident 50 stated the staff helped to clean her fingernails. Resident 50 stated she is forgetful.During an observation on 9/24/25, at 9:40 a.m., Resident 50 ate from her breakfast tray. Resident 50 had black debris under her fingernails to both hands.During an interview on 9/24/25, at 10:07a.m., CNA 2 stated he tries to clean Resident 50's nails.During a follow-up interview on 9/25/25, at 10:00 a.m., CNA 2 stated it…
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 · D2025-12-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to follow the hemodialysis (treatment to remove waste products and excess fluid from the blood when kidneys are not functioning properly) care plan for one (Resident 50) of eight sampled residents reviewed. This failure did not ensure a hemodialysis resident received the service consistent with professional standards of practice and a person-centered care plan. Findings:During an observation and concurrent interview on 9/22/25, at 10:35 a.m., Resident 50 had bandages on her left upper arm. Resident 50 stated the bandages were put on at dialysis this past Saturday, two days ago. Resident 50 stated she did not know when they were to be removed.During an observation on 9/23/25, at 9:40 a.m., Resident 50 had the same bandages from yesterday on her left upper arm. Resident 50 stated she is going to dialysis after lunch today.During a review of Resident 50's facility Face Sheet, the Face Sheet indicated an admit date [DATE] with diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-11 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure 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 provide appropriate diet texture according to physician orders for two of three sampled residents (Resident 23 and 5) when both received a minced and moist meat texture instead of chopped.These failures resulted in Resident 5 and 23 experiencing a lower quality of life when they received a less advanced diet which was not to their documented preference.A review of Resident 23's admission record titled, admission Record, dated 9/25/25, indicated Resident 23 was admitted to the facility for senile degeneration of brain and hypertension (high blood pressure).During a record review of Resident 23's minimum data set (MDS, an assessment tool to guide resident care), dated 6/24/25, the MDS indicated Resident 23 had Brief Interview for Mental Status score of 12 (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve indicates a moderate cognitive impairment.) The MDS further…
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 before2025-12-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two (Residents 9 and 69) out of eight sampled residents received appropriate catheter care per facility policy when there were inconsistent cleaning methods used by staff.This failure had the potential to result in increased risk of urinary tract infections for residents 9 and 69. Findings: During a review of the medical record titled, PACS Medication Administration Record, dated 8/26/25, the record indicated Resident 9 was admitted [DATE] with instructions to provide catheter care every shift. During a review of the medical record, dated 9/19/25, titled, Care Plan Report, the record indicated Resident 9 was at risk for complications with urinary system related to urinary tract infections (UTI- an infection of the urinary system often caused by bacteria).During a review of the medical record, dated 9/2/25, titled, SBAR Communication Form, the record indicated resident 9 had a history of benign prostatic hyperplasia (enlarged…
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 before2025-01-15 · 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 observation, interview, and record review, the facility failed to provide appropriate safety measures and adequate supervision to prevent one of three residents (Resident 1) from slipping out of bed and falling on the floor during incontinence care. The failure to provide adequate measures to prevent a dependent resident from slipping off the bed and falling onto the floor during incontinence care, resulted in Resident 1 being transported to the emergency department for further evaluation, requiring 15 stitches to maintain closure of the laceration (cut) on the right lower leg, and fracturing (partial or complete break in the bone) their right shoulder. Findings: A review of Resident 1's admission Record, printed 12/12/24, indicated Resident 1 was admitted to the facility in 2016 with diagnoses of dementia (memory loss), diabetes (high blood sugar), essential tremor (a nervous system disorder that cause rhythmic shaking), and morbid obesity (having too much body fat). A review of Resident 1's Minimum Data Set (MDS, resident assessment tool used to provide care), 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.
- Potential for harm · Ecited before2024-06-20 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure supplies stored in the Lexington medication storage room were appropriate for use when: 1. Ten Female Luer Lock Caps (a device used to seal syringes [pumps used for drawing up and expelling liquids or suspensions into the body]) were expired. 2. Two Statlock Catheter Stabilization Devices (designed to stabilize peripherally-inserted central catheters or PICCs [a long, thin tube inserted through an arm and passed through to the larger veins near the heart]) were expired. 3. One IV Catheter was expired. 4. One Kangaroo Feeding Bag Set (a spike, tubing, and bag for liquid nutrition delivery directly into the digestive tract) was expired. These failures had the potential for residents to receive expired, ineffective, and contaminated medications and treatments. Findings: During a concurrent observation and interview on [DATE], at 10:50 a.m., with Licensed Vocational Nurse 1 (LVN 1), in the Lexington medication storage area: 1. Ten…
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 18 citations
- Potential for harm · Ecited before2024-06-20 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a stock medication bottle of Senna (a laxative for short-term treatment of constipation) had a legible expiration date and was removed from resident use. These failures had the potential for the residents to receive expired and ineffective medication treatment. Findings: During a concurrent observation and interview on 6/19/24, at 3:00 p.m., with Licensed Vocational Nurse 2 (LVN 2), at the Lexington Medication Cart #4, a stock medication bottle of Senna was observed with the expiration date completely faded and not readable. LVN 2 stated, I probably should not be using this, I cannot read the expiration date, and removed it from the cart for disposal. LVN 2 stated that many residents in the facility receive Senna. During an interview on 6/20/24, at 8:19 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated medications with expired or illegible expiration dates should be removed from resident use and discarded immediately, as they may lose effectiveness. During a review of the facility's policy…
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 · E2024-06-20 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 follow kitchen practices that prevent cross-contamination and food borne illness when: 1. Chopping boards were in poor condition and stained; 2. Freezer temperature log did not have temperatures recorded for 6/15/24 and 6/16/24. These failures had the potential to cause food borne illness to a highly susceptible population of 117 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 6/17/24, at 9:15 a.m., during the initial tour of the kitchen, there were four cutting boards (white, gray, green and red) that had black marks and smudges, faded colors, scratches, and deep cuts on the surfaces. Dietary Manager (DM) stated the boards needed to be changed due to food contamination. During an interview on 6/18/24, at 10:20 a.m., with Registered Dietician (RD), RD stated deep scratches on the chopping boards carried the risk of contamination. During an interview on 6/18/24, at 10:40 a.m., DM stated kitchen inspection walk was done with RD early this month 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 · Ecited before2024-06-20 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff followed infection control procedures for four of nine sampled residents (Residents 43, 326, 331, and 328) when facility did not ensure staff: 1. washed hands with soap and water after caring for resident rooms who had clostridioides difficile (c. diff, bacteria that causes diarrhea and inflammation of the colon which can be life-threatening), 2. used appropriate germicidal wipes to disinfect equipment after use on a resident with c. diff and, 3. were trained on infection control and hand hygiene techniques. This failure had the potential for the spread of c. diff through the facility. Findings: 1. A record review of Resident 43's admission record indicated Resident 43 was admitted for enterocolitis (inflammation of the digestive tract) due to c. diff., difficulty in walking, and muscle weakness. During a record review of Resident 43's minimum data set (MDS, an assessment tool to guide resident care), dated 5/26/24, 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.
- Potential for harm · D2024-06-20 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure 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
Based on observation, interview, and record review, the facility failed to provide hygiene care in a reasonable time for one of nine sampled residents (Resident 43) when Resident 43 had to wait in stool and urine for 45 minutes before staff could change the resident. This failure caused Resident 43 to feel dejected because she had to wait 45 minutes for assistance and had the potential for Resident 43 to be at risk of skin breakdown due to exposure to urine and stool. Findings: A review of Resident 43's admission record, the record indicated Resident 43 was admitted for enterocolitis (inflammation of the digestive tract) due to clotridium difficile (a bacteria that causes diarrhea and inflammation of the colon which can be life-threatening), difficulty in walking, and muscle weakness. During a record review of Resident 43's minimum data set (MDS, an assessment tool to guide resident care), dated 5/26/24, the MDS indicated Resident 43 had a Brief Interview for Mental Status score of 14 (BIMS, was a scoring system used to determine the resident's cognitive status in regard 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 before2024-05-17 · 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 interview and record review, the facility failed to provide appropriate safety measures and adequate supervision to prevent one of two residents (Resident 1) from rolling out of bed and falling on the floor during a bed linen change. The failure to provide sufficient staff or adequate measures to prevent a dependent resident from rolling off the bed during a bed linen change, which resulted in Resident 1 being transported to the emergency department for evaluation after the fall caused a brief loss of consciousness and a headache which lasted over a week. Findings: A review of Resident 1 ' s admission Record, printed 4/10/24, indicated Resident 1 was admitted to the facility in 2017 with diagnoses of multiple sclerosis (MS, a chronic condition that affects the brain and spinal cord) and paraplegia (paralysis of the legs and lower body caused by spinal injury or a disease). A review of Resident 1's Minimum Data Set (MDS, resident assessment tool used to provide care), dated 2/2/24, indicated 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.
- Potential for harm · D2023-09-12 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1's clinical record was accurately documented when Resident 1's right heel ulcer was documented in the Treatment Administration Record (TAR) as a right lower leg ulcer. This failure had the potential to result in uncoordinated care. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included pressure ulcer (localized damage to one or more layers of the skin and/or underlying soft tissue usually over a bony prominence) of the right heel. During a review of Podiatry (branch of medicine devoted to the study, diagnosis and treatment of foot and ankle) Progress Notes dated 8/8/23, the Podiatry Progress Notes indicated Resident 1 presented to the podiatry clinic for follow-up visit for right medial (towards the middle/center) heel wound. The Progress Notes indicated current wound care as wet to dry,…
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 · D2023-08-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide necessary treatment and services for one of three residents (Resident 1), when nursing staff failed to: 1. Notify the physician or respond to Resident 1 ' s request for transfer to the acute care hospital when Resident 1 had a change of condition and asked for assistance. 2. Monitor blood oxygen as ordered for shortness of breath and provide oxygen as needed. (Oxygen saturation is a measurement of oxygen in the blood, expressed as a percentage, with 100 percent the maximum value of oxygen saturation.) 3. Administer pain medications per physician order and care plan, as needed. These failures resulted in untreated pain, emotional distress, and delayed recognition and treatment of Resident 1 ' s emergency medical condition of a pulmonary embolism. (A condition where a blood clot develops in a blood vessel in the body, becomes dislodged, travels to the lungs and blocks blood flow through a blood vessel, causing damage, potentially fatal damage, in the lungs and to the body.) Findings: 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 · Dcited before2023-08-16 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure Resident 1 ' s narcotics were recorded on both the controlled substances sheet and Medication Administration Record (MAR). This failure to follow facility policy resulted in prevention of accurate reconciliation of controlled substances. Findings: During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 3/29/23, the MDS indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status exam (BIMS, The Brief Interview for Mental Status is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) The MDS indicated Resident 1 required extensive assistance from two people for bed mobility and had not left his bed during the seven-day look-back period. The MDS indicated Resident 1 had diagnoses of peripheral venous insufficiency (impaired blood circulation in 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.
- Potential for harm · Ecited before2022-03-04 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 20 sampled residents (Resident 10 and Resident 48) received showers, bed baths and personal hygiene when: 1. Resident 10 did not receive showers or bed baths and had greasy hair and long fingernails with black matter underneath; and 2. Resident 48 had long nails with black matter underneath. These failures had the potential for Resident 10 and 48 to develop an infection from lack of proper hygiene and to injure themselves with long fingernails. Findings: 1. During a review of Resident 10's admission Record Report, dated 3/4/22, the admission Record Report indicated Resident 10 was admitted to the facility on [DATE] and had medical diagnoses including type 2 diabetes mellitus (body cannot regulate own blood sugar) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). During a record review of Resident 10's Minimum Data Set (MDS, a resident assessment tool used to guide care) 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.
- Potential for harm · E2022-03-04 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
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 two of 29 sampled residents' (Resident 63 and 67) body weights were monitored according to physician's orders when Resident 63 and 67's body weight records were missing. This failure put Resident 63 and 67 at risk for not receiving appropriate evaluations, interventions and or modifications to manage the causes for nutritional risks. Findings: 1. During a review of Resident 63's admission Record Report, dated 3/4/22, the admission Record Report indicated Resident 63 was initially admitted to the facility on [DATE] with medical diagnoses including pressure ulcer (damage to the skin or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction) of right ankle, type 2 diabetes mellitus (body cannot regulate own blood sugar), and dementia (memory loss). During a concurrent interview and record review on 3/1/22, at 3:24 p.m., with Registered…
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 · E2022-03-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Oxygen (O2) and CPAP (a machine that helps maintain the airway remain open by providing a steady flow of air at constant pressure) physician orders were established and followed for one of 29 sampled residents (Resident 27) when resident 27 used O2 and CPAP as needed without physician orders. This failure had the potential for Resident 27 to receive the wrong dose of O2 and to use the CPAP at a wrong setting. Findings: During a review of Resident 27's admission Record Report dated 3/4/22, the admission Record Report indicated Resident 27 was originally admitted to the facility on [DATE]. During a review of Resident 27's Physician Progress Notes, dated 12/7/21, the progress notes indicated Resident 27 has a diagnosis of O2 dependent chronic obstructive pulmonary disease (COPD, constriction of airways and difficulty breathing), obstructive sleep apnea (OSA, a disorder in which a person frequently stops breathing during sleep) and was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its medication error rate did not exceed five percent for one of four sampled residents (Resident 18). There were two medication errors out of 25 opportunities resulting in an eight percent (%) medication error rate when Resident 18 did not receive Amlodipine Besylate (medication for high blood pressure) and the wrong dose of Folic Acid (a vitamin supplement to help make red blood cells) was administered. This failure resulted in Resident 18 not receiving medications per physician orders and it had the potential for Resident 18 to experience uncontrolled high blood pressure. Findings: During a record review of Resident 18's admission Record Report, dated 3/4/22, the admission Record Report indicated Resident 18 was admitted to the facility on [DATE] with diagnoses that included chronic atrial fibrillation (irregular heart rhythm), type 2 diabetes mellitus (body cannot regulate own blood sugar), hypertension (high blood pressure),…
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 before2022-03-04 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 monitor room temperature for one of two medication storage rooms (Med room [ROOM NUMBER]) from 12/2021 through 1/2022. This failure had the potential to affect the potency and effectiveness of medications stored in Med room [ROOM NUMBER]. Findings: During a concurrent interview and record review on 3/2/22, at 10:31 a.m., with Registered Nurse 1 (RN 1), in Med room [ROOM NUMBER], the Medication/Vaccine Refrigerator Temperature Log - California, dated 12/2021 and 1/2022 for Med room [ROOM NUMBER] were reviewed. The Medication/Vaccine Refrigerator Temperature Log - California for 12/2021 indicated, If storing vaccines in refrigerator, take temperature two times each day in a.m. and p.m. If storing only medications and no vaccines, one time a day is acceptable. The temperature log also indicated the facility did not monitor Med room [ROOM NUMBER]'s refrigerator, freezer, and room temperature for nine days from 12/23/21 through 12/31/21 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 · E2022-03-04 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure food served was attractive and palatable for one of five sampled residents (Resident 36) when over cooked, brown peas were served for lunch. This deficient practice had the potential to impact Resident 36's nutritional status. Findings: During an interview on 2/28/22, at 11:15 a.m., with Resident 36, Resident 36 stated the food at the facility was either over cooked or not well cooked. Resident 36 further stated the facility at times served overcooked vegetables. During a concurrent observation and interview with the Food Service Director (FSD), on 3/1/22, at 1:29 p.m., green peas mixed with brown peas were observed on the lunch test tray. FSD stated the brown peas were over cooked because of the heat from the steam table. FDS stated food should be palatable, the right temperature and presentable. FSD stated the brown peas did not look presentable. FSD stated the pan with the peas should have been changed out every 20 minutes during tray line. FSD stated she was unsure if the pan of peas was changed…
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 before2022-03-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to follow COVID-19 (a respiratory disease caused by the SARS-CoV-2 virus) infection procedures for one of one sampled resident (Resident 101) when Resident 101 was not tested for COVID 19 after admission from the acute care hospital and proper signage and Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards) was not provided. This practice had the potential for the spread of COVID-19 infections to residents and staff. Findings: During a record review of Resident 101's admission Record Report, dated 3/4/22, the admission Record Report indicated Resident 101 was admitted on [DATE]. During a record review of Resident 101's Admission/re-admission Evaluation, dated 3/1/22, the Admission/re-admission Evaluation indicated Resident 101 did not receive an additional dose above the manufacturer recommended primary series of the COVID-19 vaccine. During a concurrent observation and interview on 3/2/22, at 8:10 a.m., with…
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 · D2022-03-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident room doorknob was properly working and tightly fastened to the door for one of 29 sampled residents (Resident 19) when Resident 19's room doorknob was loose. This failure had the potential for Resident 19 to experience a fall and avoidable injuries. Findings: During a record review of Resident 19's Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 12/7/21, the MDS indicated Resident 19 was recently admitted to the facility on [DATE]. The MDS also indicated Resident 19 was not steady and required staff assistance for balance during movement from a seated to standing position and during walking. During an observation on 2/28/22, at 11:10 a.m., the doorknob of Resident 19's room was loose. During a concurrent observation and interview on 2/28/22, at 11:41 a.m., Registered Nurse 8 (RN 8) stated the doorknob to Resident 19's room needed to be fixed. RN 8 stated she was not aware about the loose…
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 · D2022-03-04 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to act upon consultant pharmacist's recommendations for Gradual Dose Reduction (GDR, stepwise tapering of a dose to determine if symptoms, conditions or risks can be managed by a lower dose or if the dose or the medication can be discontinued) for multiple psychotropic (medications that affect brain activity) medications and a diagnosis clarification for one of 29 sampled residents (Resident 33) when Resident 33's psychotropic medications' dosages remained unchanged for two consecutive months. This failure placed Resident 33 at risk to receive psychotropic medications at a higher dose. Findings: During a review of Resident 33's admission Record Report dated 3/4/22, the admission Record Report indicated Resident 27 was admitted to the facility on [DATE] and has a medical diagnosis of dementia. During a record review of Resident 33's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 12/25/21, the MDS indicated Resident 33 had…
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 · D2022-03-04 · 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
Based on observation, interview, and document review, the facility failed to identify the indications for use of a psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication for one of one sampled resident (Resident 87) when specific behavior was not identified and clinical rationale was not documented for administering Quetiapine (an antipsychotic medication that affects brain activity associated with mental process and behavior). This failure did not ensure Quetiapine medication was an appropriate medication to treat Resident 87's medical diagnosis of Parkinson (a movement disorder that affects the ability to perform common daily activities). Findings: During a review of Resident 87's current Physician's Order, it showed an order dated 2/15/22 for Quetiapine fumurate 25 milligram tablet, give 1 tablet orally two times a day for Parkinson. During a concurrent interview and record review on 03/03/22, at 9:04 a.m., with RN 3, Resident 87's Medication Administration Record (MAR) was reviewed. RN 3 stated Resident 87 was admitted from…
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 PACS GROUP — 274 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 | 2.9 | +2.1 vs chain |
| Health inspection | 4 of 5 | 2.5 | +1.5 vs chain |
| Staffing | 4 of 5 | 2.5 | +1.5 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; lowest-rated first.
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 |
|---|---|---|---|
| TRUIST BANK | Organization | 5% OR GREATER MORTGAGE INTEREST | since 12/07/2023 |
| JERGENSEN, JOSHUA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2024 |
| LONDONO, ADRIANO | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/03/2025 |
| MITCHELL, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2024 |
| PATEL, ASHISH | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| OYLER, ABRAHAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2025 |
| PROVIDENCE ADMINISTRATIVE CONSULTING SERVICES INC | Organization | ADP OF THE SNF | since 02/01/2024 |
CMS files one row per role, so the 14 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.
2 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 $468K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 555710. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, 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 →
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