Shasta Healthcare
445 Park Street, Weed, CA 96094 · For profit - Corporation · 59 certified beds · (530) 938-4429 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $84,526 in federal fines (most recent 2025-09-12)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 3 of 5 |
| Long-stay residentspeople who live here | 2 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 improved from 2 to 3 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 | 31.3% | 10.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.2% | 4.0% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 2.9% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 6.2% | 1.2% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 12.8% | 7.3% | 6.5% | worse |
| 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 | 7.0% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 22.9% | 9.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.0% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 93.8% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.2% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.4% | 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 table | 2.6% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.9% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 16.6% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 14.0% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.26 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 3.08 | 1.57 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
57.7% 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 205 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.0% 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 69 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 57.7%CMS range 51.4–63.5 | 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 | 11.1%CMS range 7.8–15.0 | 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 | 58.0% | 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 | 50.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.7% | 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 | 97.1% | 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 | 95.2% | 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 | 2.0% | 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 | 1.0% | 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 | 5.7%CMS range 3.3–9.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.13 | 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 59 beds and averages 37.0 residents a day — about 63% occupied, or roughly 22 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.65 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 3.91 hrs/resident/day on weekends vs 5.03 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.81 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 13 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · L2024-07-24 · tag F0684 — failed to provide proper treatment and quality of care — widespreadProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that there was an alternative system in place by which resident Medication Administration Records (MARs), Treatment Administration Records (TARs), and Physician's Orders, could be accessed by staff in the event that the facility's Electronic Medical Record system (EMR, a computerized system that contained resident MARs, TARs, and Physician's Orders), was not available for 41 of 41 residents. On 7/17/24, the facility's EMR system administrator notified the facility that there was going to be a scheduled outage for EMR maintenance and that the EMRs would not be available on 7/18/24. The facility took no action to prepare for this planned outage and subsequently had no way for the nurses to administer medications, treatments (wound and skin care), or see what the physician currently had ordered for each resident. This failure resulted in the nursing staff ' s inability to know what each resident ' s current physician ' s orders were, therefore, the nursing staff was unable to administer medications or do wound care…
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.
- Immediate jeopardy · K2024-07-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 1), sampled for unsafe wandering (a random, aimless or repetitive search for an exit that is non-goal-directed), and elopement (a resident leaves the premises or a safe area without the facility's knowledge and supervision) was assessed and monitored for unsafe wandering and elopement. Resident 1 eloped twice from the facility and had no wander/elopement risk assessments or care planning done, and the facility had no dedicated alarm system in place for residents who wandered or were at risk to elope. This resulted in Resident 1 eloping from the facility and was found by the police in a ditch near a highway with a scratched face, bruised chin and pain in her right leg. An Immediate Jeopardy (IJ) situation was identified on 7/2/24 at 4:18 pm, in the presence of the Administrator (Admin) and Director of Nursing (DON), due to not having an elopement system in place that ensured the health, safety 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.
- Actual harm · G2025-09-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure that a resident who entered the facility without a pressure injury (PI, a bedsore) did not develop a PI, for one of two residents sampled for PI (Resident 1). Resident 1 developed a PI to her sacrum (bottom of the spine), which progressively worsened and the facility failed to follow their policies regarding wound care and changes of condition and inform Resident 1's physician when her PI changed and worsened.This delayed treatment for Resident 1's PI by six days, and resulted in a worsened and infected PI. Within two days of Resident 1 discharging from the facility, she was admitted to the acute care hospital for an infected PI and sepsis (an infection in the bloodstream) and osteomyelitis of the sacrum (an infection in the bone). This failure had the potential to delay wound healing for any resident who had wounds and/or PI's and subject them to substandard quality of care.Refer to F726 Findings:Review of the National 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 · Fcited before2026-04-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to ensure food safety and sanitation guidelines were followed when:There was an undated gallon of milk in the refrigerator that was partially used, undated bags of bread in the dry goods storage area, an undated box of individual jelly packets in the dry goods storage area.There was a box of potatoes stored on the floor of the dry goods storage area, and a box of paper dining napkins stored on the floor of an outdoor storage area.There was brown crusty debris on baking pans, and the red and green cutting boards had cuts in the surfaces.The ice machine had a pale brown substance in the internal ice chute (where the ice comes down from the storage bin).These failures had the potential to cause foodborne illnesses for all residents of the facility who ate food prepared by the kitchen and used ice.Findings:During a tour of the kitchen on 4/21/26 at 9:58 am, the Dietary Aid (DA) confirmed there was a gallon of milk in the refrigerator which was not dated upon opening and that it should have been dated.During a tour…
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 · D2026-04-24 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to ensure that one of twelve residents sampled (Resident 8) right to have an Interdisciplinary Team Meeting (IDT meeting, a meeting where the Interdisciplinary Team, a group of facility managers, discuss the care and services that the facility provides to their residents) with all the team members present to ensure decisions made regarding Resident 8 was in their best interest.This failure had the potential to result in decisions being made about Resident 8's health care that were not in their best interest.Refer to F841Findings:Review of a facility policy titled Consent: Residents Unable to Provide Informed Consent and Without a Health Care Decision-Maker- CA reviewed 1/16/26 indicated, It is the policy of this facility that an Interdisciplinary Team can make treatment decisions for residents when a physician determines that resident is unable to provide informed consent for a proposed treatment intervention because they cannot articulate…
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 · D2026-04-24 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility did not ensure one out of 12 sampled residents (Resident 46) was able to safely self-administer medication when Resident 46's Albuterol inhaler (a fast-acting medication that opened the airways in the lungs and made breathing easier) was stored at the bedside and available for use. This had the potential for overdosing or incorrect usage which could lead to a decline in health status. Findings: A review of the facility's policy and procedure (P&P) titled, Medication, Storage at Bedside, dated 1/16/26, indicated, that medications could only be kept at a resident's bedside if there was a Physician's order and the Interdisciplinary Team (IDT, a group of medical professionals who met to discuss residents' care) had evaluated and approved the safety of self-administration A review of Resident 46's admission Record, dated 4/14/26, indicated admission to the facility on 4/14/26 with the diagnoses of atrial fibrillation (top part of the heart shakes instead of beating effectively causing an irregular heartbeat) 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 · D2026-04-24 · tag F0572 — isolatedGive residents a notice of rights, rules, services and charges.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility did not ensure there was ongoing communication regarding resident rights during group activities. This had the potential for residents not to know how to effectively exercise their rights.Findings: A review of the Resident [NAME] of Rights, dated 8/1/25, indicated that residents had the right to be fully informed of their rights at the time of admission and during their stay in the facility. A review of the Resident Council Minutes, dated 10/23/25 through 4/16/26, did not include any information about resident rights being discussed. During an interview on 4/23/26 at 10:01 am, five out five confidentially interviewed residents were asked if the facility talked about or reviewed resident rights with them. Five out of five confidential residents indicated resident rights were not discussed during Resident Council meetings (a group of residents that meet monthly to discuss care concerns and their rights). Activities Director (AD) was present during the Resident Council at the request of the residents and confirmed, resident rights…
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 · D2026-04-24 · tag F0577 — isolatedAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 the most recent recertification survey (an evaluation of the facility to ensure they are compliant with federal regulations, and clinical quality) was available to the residents of the facility.This failure resulted in a violation of resident rights. Findings:During a confidential interview of facility Resident Council (a group of residents who regularly meet to advocate for their right) on 4/23/26 at 10:01 am, the attendees of the meeting indicated that they did not know where in the facility to find the results of surveys conducted at the facility.During a concurrent observation and interview on 4/23/26 at 10:37 am the Director of Nursing (DON) confirmed that the survey results binder was in the foyer (an entrance hall or entryway that acts as a transitional space between the outdoors and the main areas of a building, in which there is an outdoor entrance, followed by a room, and then another set of doors leading into the main area of the building) where any resident who could not open the interior…
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 · D2026-04-24 · 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 record review, the facility failed to ensure two out of twelve sampled residents (Resident 6 and Resident 25) received the necessary services to maintain good personal grooming and hygiene when:1. Resident 6 did not receive a shower for twelve days.2. Resident 25 had a dark unknown substance crusted under their fingernails.These failures resulted in frustration and discomfort for Resident 6 and placed Resident 25 at risk for negative health outcomes related to poor hand hygiene.Findings: 1.Review of a facility policy titled ADLs (Activities of Daily Living e.g., feeding, bathing, dressing), Services to carry out reviewed 2/1/26 indicated, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities.2. Residents who are unable to carry out activities of daily living will receive necessary services to maintain.Personal hygiene. Review of Resident 6's admission record indicated admission to 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 · D2026-04-24 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
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 two of two Certified Nurse Aid (CNA) staff currently providing resident care received a performance evaluation annually. This resulted in the facility failing to asses staff's knowledge and skills to ensure staff had adequate skills and knowledge to provide quality care to all residents. During a concurrent interview and record review, on 4/24/26 at 9:00 am, with the Director of Nursing (DON) and the Director of Staff Development (DSD), both confirmed that a process to ensure all CNAs received annual evaluations had not been implemented by the facility. DSD indicated she was aware that staff performance evaluations had not been carried out annually, but was unclear how long this had been an ongoing problem. DSD confirmed that the annual evaluations were necessary to identify areas where training was needed. Both DON and DSD confirmed that these evaluations had not yet been initiated for CNA's B and C. During an interview and concurrent record review, on 4/24/26 at 11:00 am, CNA B and CNA C's employee files were…
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 · D2026-04-24 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure their medication error rate was less than 5 percent (5%), when the Medication Administration Pass Observation reflected three medication errors out of 25 opportunities resulting in a medication error rate of 12 percent (12%) as evidenced by: Resident 8 was not provided with a Physician ordered medication,2a. Resident 46 was not provided with a Physician ordered medication; and2b. Resident 46 was administered a higher dose of a medication than what the Physician ordered. This had the potential for residents to not attain or maintain their highest practicable level of physical, mental, functional and psycho-social well-being and have adverse medication outcomes.Findings: 1. A review of the facility's policy and procedure titled, Medication Administration, dated 1/16/26, indicated, medication would be administered as prescribed by the Physician. A review of Resident 8's admission Record, dated 9/29/25, indicated, admission to the facility on 9/29/25 with the diagnosis of bipolar disorder (a mental…
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 · D2026-04-24 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility did not ensure that medications stored in one of two medication carts contained labels for use that matched the Physician's orders for Resident 8. This failure had the potential to cause a medication error or for medication to run out early. Findings: A review of the facility's policy and procedure (P&P) titled, Labeling and Storage of Drugs, dated 1/16/26, indicated, medication labels would include specific directions for use. The P&P indicated, when the medication label was incorrect, the medication would be returned to the pharmacy, or the Licensed Nurse (LN) would flag the medication label indicating there was a change in the directions for use. A review of Resident 8's admission Record, dated 9/29/25, indicated, admission to the facility on 9/29/25 with the diagnoses of mild cognitive impairment (a decline in memory or thinking that was not related to normal aging) and breakdown of internal fixation device (hardware such as metal plates, rods, or screws) of right humerus (upper arm bone). During a concurrent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-24 · tag F0841 — isolatedDesignate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and policy review, the facility did not ensure that the Medical Director (MD) effectively implemented resident care policies for one of two sampled residents (Resident 8) when:1. The facility failed to obtain a resident representative (RP, medical decision maker) who was unaffiliated with the facility (a person who is not connected to the business) for Resident 8.2. The MD acted as Resident 8's RP.This had the potential to result in decisions that were in the interest of the facility rather than the interest of Resident 8.Findings:Review of a facility policy titled, Consent: Residents Unable to Provide Informed Consent and Without a Health Care Decision-Maker - CA, reviewed 1/16/2026, indicated that the facility was responsible to assist residents in obtaining an RP if they were no longer able to make their own decisions, or had no family who could fill that role.Review of a facility policy titled Compliance Manual undated, indicated Personnel and employees.should not place themselves in a position where their actions, or the activities or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2026-04-24 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop, implement, and maintain an in-service training program for two of two Certified Nursing Assistants (CNAs) to ensure areas of deficiencies in job performance that were identified during annual performance reviews were addressed and ensure that the facility provided 12 hours of continuing education for CNAs. This had the potential to negatively impact the quality of care to residents, particularly those with specialized care needs such as those with dementia or other cognitive impairments.Findings:During a concurrent interview and record review on 4/24/26 at 9:00 am, with the Director of Nursing (DON) and the Director of Staff Development (DSD,) both were asked to described the facility's current training program for Certified Nurse Assistant (CNA) staff. DSD stated she did not have documentation of in-service trainings to meet the annual requirement of 12 hours of training that included dementia management, abuse training, and training to address any areas of weakness identified during annual evaluations. DON 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 · D2025-09-12 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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, record review, and policy review, the facility failed to ensure safe discharge for one of two residents sampled (Resident 1), when Resident 1 chose to leave the facility Against Medical Advice, (AMA, when the physician does not agree with the resident leaving the facility because of their medical condition) and the facility failed to ensure;1. There was a physician's order to discharge Resident 1 AMA.2. Discussion and documentation was done with Resident 1 of alternatives to discharging AMA to the location to which Resident 1 discharged .3. An Against Medical Advice form (A form that a resident signs acknowledging understanding of the consequences for leaving the facility AMA), was not offered to Resident 1.4. A facility investigation was done and an Adult Protective Services (A government service to protect vulnerable individuals in the community from abuse, neglect and exploitation) report filed.These combined failures resulted in Resident 1 not being informed by the facility of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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, record review, and policy review, the facility failed to ensure the care plan (a document that outlines a patient's health care needs and the actions and interventions required to address them), was revised and updated when one of two sampled residents (Resident 1), had a pressure injury (PI, a bedsore) that worsened and the care plan had not reflected this.This failure resulted in no identified problem, goals or interventions to promote the healing of Resident 1's PI to her sacrum (the large triangular bone at the base of the spine), and inconsistencies and delayed treatments of Resident 1's PI, which had a negative impact on her clinical status.Findings:Review of a facility policy titled, Goals and Objectives, Care Plans revised April 2009, indicated, 5. Goals and objectives are reviewed and/or revised: a. when there has been a significant change in the resident's condition.Review of the National Pressure Injury Advisory Panel's (a nationally recognized professional resource for the staging…
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 · D2025-09-12 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure nursing staff demonstrated competency in following the facility's policies in regard to wound care management and changes in resident conditions for one of two sampled residents (Resident 1) when;1.Registered Nurse (RN) A and Wound Care Nurse/ RN (WCN/RN), had not notified Resident 1's physician that Resident 1's sacrum (base of the spine) pressure injury (PI-a bedsore), had worsened. 2.WCN/RN performed conservative sharp wound debridement (CSWD, an invasive procedure to remove dead tissue from a PI using sharp instruments such as a scalpel (knife), scissors, and forceps (tweezers)), to Resident 1's PI, without a physician's order. These cumulative failures caused in a delay in the treatment and healing of Resident 1's PI and caused the PI to worsen. Subsequently, Resident 1 was hospitalized within two days after she left the facility, for sepsis (an infection in the blood stream) and osteomyelitis of the sacrum (an infection in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent verbal abuse for one of three sampled residents, (Resident 2) when Certified Nursing Assistant (CNA) A cursed at Resident 2. This failure violated Resident 2's right to be free from abuse and had the potential to negatively impact Resident 2's emotional and psychosocial well-being. Findings: Review of the facility's policy titled, Abuse Prevention Program, dated December 2016, indicated, Our residents have the right to be free from abuse . and As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone . Review of the admission record for Resident 2, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including diverticulitis of large intestine (a condition where small pouches in the lining of the large intestine become inflamed or infected), type 2 diabetes (high blood sugar), depression, and complications of colostomy (a surgical procedure that brings one end of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-15 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
2. A facility policy titled, Handwashing/Hand hygiene, revised 10/2023, indicated, 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to the other personnel, residents, and visitors. A facility policy titled, Med [Medication] Pass Infection Control Review, dated 06/01/2023, indicated, Do not touch meds [medications] with ungloved hands. The policy specified, Use hand hygiene prior to handling medication and after administering to resident. Place a barrier between the cart and the medication while preparing the medication. A Resident Face Sheet, indicated the facility admitted Resident #15 on 09/10/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of hypertension, paroxysmal atrial fibrillation, angina pectoris, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2024, indicated Resident #15 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-15 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review, the facility failed to lock the computer screen on 1 of 2 medication carts to ensure residents' protected health information (PHI) was not visible for all to see. Findings included: An undated facility policy titled Security of Medication Cart indicated, The cart must be locked with the computer charting system secured prior to entering the resident's room.4. Medication carts must be securely locked at all times when out of the nurse's view. During an observation on 01/14/2025 at 7:50 AM, the surveyor noted the computer on the medication cart was left unlocked and Resident #28's list of medications and other PHI for other residents was visible. The nurse assigned to the medication cat was not present. At 8:05 AM, the surveyor was told the nurse assigned to the medication cart was in the dining room. The surveyor observed Licensed Vocational Nurse (LVN) #1 in the dining room. LVN #1 stated she could not leave the dining room for another 30 to 35 minutes. LVN #1 acknowledged she could not visualize the medication cart 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.
- Potential for harm · Dcited before2023-11-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents, (Residents 1 and 3) who were roommates, were free from verbal abuse when Certified Nursing Assistant (CNA) B yelled profanities at Resident 1 and 3 while in their room and continued yelling profanities in the hallway within hearing range after CNA B left the resident's room. This failure resulted in anger, frustration, and humiliation for Residents 1 and 3, and had the potential to negatively impact the emotional and psychosocial well-being of all the residents that CNA B cared for. Findings: During a review of the facility's policy, revised 7/2017 titled, Abuse and Neglect -Clinical Protocol, the policy indicated, Abuse is defined as the willful infliction of injury. Instances of abuse for all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish, includes verbal abuse. This facility's policy also indicated willful as used in the definition 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 before2023-11-06 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record and Abuse Policy review, the facility failed to report an abuse allegation within the mandated timeframe for two of five sampled residents (Resident 1 and 3), when Certified Nursing Assistant (CNA) C witnessed CNA B cursing and yelling at Residents 1 and 3 around 10 pm on 9/20/23, and had not reported this until around 6:30 am on 9/21/23, about 8 hours later. This had the potential for abuse to continue to all residents and negatively impact their safety and emotional well-being, by not initiating investigations and protecting the residents immediately. Findings: A review of the facility's policy titled, Abuse Investigation and Reporting, revised July 2017, indicated all types of resident abuse shall be promptly reported to local, state, and federal agencies. This facility's policy indicated an alleged violation of abuse will be reported immediately, but no later than 2 hours. During a review of the facility's policy, revised 7/2017, titled, Abuse and Neglect -Clinical Protocol, indicated Abuse is defined as the willful infliction of injury.…
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 before2023-08-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistants (CNA) 2 and CNA 3 reported allegations of staff to resident abuse for one of two sampled residents (Resident 1), when they witnessed CNA 1 allegedly Roughly placing Resident 1 into a shower chair on 5/23/23, and did not report this to the Abuse Coordinator or anyone else in the facility. This failure had the potential to put all residents at risk for abuse from CNA 1 and prevent the facility from reporting, protecting and investigating abuse allegations. Findings: A review of the facility ' s policy titled, Abuse Prevention Program, revised December 2016, indicated Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident ' s symptoms. This…
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 · E2022-07-21 · tag F0801 — patternEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 adequate oversight of the Food and Nutrition Services by qualified personnel when: 1. The Registered Dietitian did not conduct regular audits of the Food and Nutrition Services to ensure food safety and sanitation practices and meal service requirements were in place and followed. 2. The facility's therapeutic menus and diet manual were not reviewed and signed off by the facility's Registered Dietitian and did not include all diets routinely ordered by providers at the facility. 3. The Dietary Services Manager did not complete the required six hours of State regulatory training prior to assuming the leadership role. These failures had to potential to result in non-compliance with physician ordered diets, inadequate provision of nutrients, promote foodborne illness, and to negatively affect overall health for residents living in the facility. Findings: Review of a job description provided by the facility titled Dietitian dated 2001,…
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 · E2022-07-21 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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 ensure their menus met resident needs when: 1. Therapeutic fortified diets served in the facility were not included in the facility-specific diet manual or cooks spreadsheets and had not undergone nutrient analysis to ensure resident nutrition needs were being met. 2. Staff did not use standardized recipes to ensure nutrient content for foods served to residents on fortified diets. 3. The current menus had not been updated in more than three years, were not seasonal, and were not signed off by the facility's Registered Dietitian. These failures had the potential to result in staff providing or not providing food to ensure compliance with the physician's written diet order, and to result in resident's nutritional needs not being met. This could negatively impact residents' health. Findings: Fortified diets are intended to boost calories and/or protein of routinely consumed foods by about 500 calories per day through the addition 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 · Ecited before2022-07-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure sanitation of the Food and Nutrition Services Department when: 1. The ice machine was not sanitary. 2. Staff did not follow manufacturer's instructions when using their Sink and Surface Cleaner Sanitizer to clean food production equipment and surfaces. 3. Food preparation equipment and storage areas were not clean. 4. Staff did not exhibit professional standards of practice to decrease the likelihood of cross contamination during food production activities. 5. The storeroom floor had a buildup of black grime, and the floor drain was not sanitary. 6. An air gap device was not present in the food preparation/ manual warewashing sink. These failures had the potential to increase the risk of foodborne illness for residents living in the facility. Findings: Review of the FDA Food Code 2017, Annex 4 - §602.13 showed The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth 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 · E2022-07-21 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 effective pest control system when insects resembling flies were present in multiple locations in the facility during the survey. This failure has the potential to result in transmission of disease to residents living at the facility. Findings: Review of the Food and Drug Administration (FDA) Food Code 2017, 6-501.111 showed: The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: (A) Routinely inspecting incoming shipments of food and supplies; (B) Routinely inspecting the premises for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or, other means of pest control (D) Eliminating harborage conditions (conditions that encourage pests to live and grow). Review of a policy titled Pest Control dated 2001, revised 2008 showed Our facility shall maintain an effective pest control program .This facility maintains an on-going pest…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-21 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 clinical record review, the facility failed to ensure that 3 of 12 sampled residents' (Residents 12, 20, and 2) nutritional care plans were person-centered, comprehensive and reviewed or revised by the interdisciplinary team (IDT- professional disciplines that work together in the best interest of the resident) when: 1. Resident 12's Nutritional Status care plan was created on 6/1/22, and was not revised to show that he had significant weight loss. 2. Resident 20's Nutritional Status care plan was created on 4/8/22, and not revised to show that she had significant weight loss. 3. Resident 2's Nutritional Status care plan was created on 2/23/22, and not revised to show he had significant weight loss and weight gain. This had the potential for person-centered approaches used to resolving these residents' weight changes not being identified and interventions not implemented, which may result in continued weight loss. Findings: The facility's policy titled, Care Plans,…
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 · D2022-07-21 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility administration failed to ensure adequate oversight and provision of Food and Nutrition Services by qualified personnel when: 1. There was no full-time Dietary Services Manager (DSM), the position responsible for daily operations of the department and supervision of foodservice staff, from November 2021 through April 2022 when the dietary manager was out on leave of absence. 2. There was not a system in place to ensure the Registered Dietitian's training and competence in use of the facility's electronic medical record. These failures had the potential to result in inadequate supervisory coverage of Food and Nutrition Services responsibilities, and inadequate nutrition care documentation that could negatively impact food services and nutrition care for residents. Findings: 1. There was no full-time Dietary Services Manager (DSM), the position responsible for daily operations of the department and supervision of foodservice staff, from November 2021 through April 2022 when the dietary manager was out on leave of absence.…
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 · D2022-07-21 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working 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 adequately maintain equipment in the Food and Nutrition Services equipment when: 1. Two out of two freezers had ice buildup, potentially impacting the function and life of the freezers and the quality of food inside. 2. One freezer and one refrigerator had rusty shelves. 3. The cold food preparation area counter and cabinet had uncleanable surfaces. These failures had the potential to result in cross-contamination of food, loss of food, loss of food storage ability if freezers failed, and loss of food quality for residents. Findings: Review of the 2017 FDA Food Code §4-501.11 showed Proper maintenance of equipment .helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures. Additional review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2022-07-21 · tag F0641 — widespreadEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately reflect the cognitive status for one of twelve sampled residents (Resident 20) when they failed to complete the Minimum Data Set (MDS), a required assessment tool. This failure had the potential for staff to be unaware of the level of memory and cognitive deficit experienced by Resident 20, which in turn could have placed her at risk for harm. Findings: Resident 20's medical record was review, Resident 20 was admitted on [DATE] with Alzheimer's dementia, a degenerative brain disease that affects memory, thinking and behavior. Resident 20's medical record most recent MDS was dated 7/5/22. Section C of the assessment, Cognitive Patterns, has a designated area for a summary score based on an exam titled the Brief Interview for Mental Status (BIMS) which demonstrates an individual's memory retention capability. BIMS scores range from 1-15 and indicate an individual's level of impairment, or a score of 99 to indicate the individual was unable 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.
“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
$84,526 in federal fines across 2 penalties.
- $24,518 — penalty dated 2025-09-12
- $60,008 — penalty dated 2024-07-12
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EMERSON, CHERYL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 21% | since 12/11/2015 |
| EMRY, KENT | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER | 58% | since 12/11/2015 |
| PHELPS, JULIE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 21% | since 12/11/2015 |
CMS files one row per role, so the 9 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
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 $962K paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055807. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-24, 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.