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Whittier Nursing And Wellness Center, INC

7926 S Painter Ave, Whittier, CA 90602 · For profit - Corporation · 36 certified beds · (562) 693-5618 Medicare & Medicaid certified

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Behavioral-health or dementia-care citation at the harm level (F0740)1 immediate-jeopardy citation$13,627 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (20% vs 45% nationally) — better care continuity
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $13,627 in federal fines (most recent 2024-09-19)
  • about 22% of its spending goes to commonly-owned related companies

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

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

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
7749 Painter Ave · (562) 945-6391 · Call to confirm hours
Pharmacy
8201 Greenleaf Ave · (562) 698-4906 · Call to confirm hours
Grocery
13003 Whittier Blvd · (562) 907-7037 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

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

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.0%10.2%15.4%typical
Long-stay residents who lose too much weight4.8%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened2.8%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.8%13.7%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers0.0%4.3%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control0.0%10.2%21.2%check this — see note marked star below the table
Long-stay residents who got an antipsychotic medication — see the note below the table22.7%12.0%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission18.9%23.0%22.6%better
Short-stay residents with an outpatient ER visit4.0%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days2.342.251.67worse
Long-stay outpatient ER visits per 1,000 resident days0.271.571.80better

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

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

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

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

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

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

22.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 83 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

22.0%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
83.8%U.S. median 56.6%
Met the expected recovery
0.43U.S. median 0.31
Therapy hours / resident / day
0.26hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 83.8% 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 74 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 68% of this home’s weekday level — it runs therapy at close to weekday levels right through 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF22.0%CMS range 14.6–31.651.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 7.5–15.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge83.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge75.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge75.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.4%CMS range 3.3–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.251.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.35
RN hours/ resident / day
0.94
LPN hours/ resident / day
2.87
Aide hours/ resident / day
4.16
Total nurse hours/ resident / day
0.31
RN hoursweekends
20.0%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 36 beds and averages 34.6 residents a day — about 96% occupied, or roughly 1 bed 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 4.16 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.87 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 4.19 hrs/resident/day on weekends vs 4.15 on weekdays — about the same on weekends as weekdays. RN hours go from 0.36 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

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

Inspection trend

7
deficiencies at the latest standard inspection (2025-12-04)
8
at the previous standard inspection (2024-11-07)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Jdisputed · IDR2024-09-19 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 interview and record review, the facility failed to provide necessary services (drug counseling and surveillance [monitoring of behavior; activities]) and develop person centered care plans for the behavioral healthcare needs for substance abuse for one of three sampled residents (Resident 1), who had a history of drug abuse (the excessive or addictive use of drugs for nonmedical purposes) and prevent Resident 1 from experiencing a drug overdose (an excessive and dangerous dose of a drug) of opiate (a controlled drug used to treat pain or cause sleep) and fentanyl (a powerful, controlled drug that is used to treat severe pain) while residing in the facility by failing to: 1. Develop and implement behavior health care plans for drug abuse to meet the behavioral needs of Resident 1 ' s when Resident 1 was readmitted to the facility from the General Acute Care Hospital 2 (GACH) on [DATE] in accordance with the facility policies and procedures [P&P] titled Behavioral assessment, intervention and monitoring…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-04 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours seven days a week in the facility including the following weekends: 10/18/2025, 10/19/2025, 10/25/2025 10/26/2025, 11/16/2025/ 11/22/2025, and 11/29/2025 that care for 30 or 30 residents in the facility. This deficient practice had the potential for the residents' care not to be supervised and assessed clinically by the RN which could affect the quality of care and quality of life of the residents. Findings: During a review of the facility's Direct Care Service Hours Per Patient Day (DHPPD, a staffing metric ensuring enough caregiver time per resident, calculated as total direct care hours divided by patient census) from 9/2025 to 11/2025, indicated there was no RN on duty for 8 consecutive hours for the following dates: 10/18/2025, 10/19/2025, 10/26/2025, 11/16/2025/ 11/22/2025, and 11/29/2025 in the facility. During an interview with the Director of Nursing (DON) on 12/3/2025 at 1:42 PM, the DON stated the facility did not require an RN for 8 hours on the weekends…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-04 · tag F0732 — pattern
    Post nurse staffing information every day.
    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 that accurate and current nurse staffing data [total number and actual hours worked by licensed (Registered Nurses [RNs], License Vocational Nurses [LVNs]) and unlicensed nurses (Certified Nursing Assistant [CNAs])] were posted daily at the beginning of each shift (11 PM - 7 AM, 6:30 AM - 3 PM, and 3 PM - 11 PM) to care for 30 residents of 30 residents. These deficient practices of posting inaccurate and outdated nurse staffing data had the potential to mislead and prevent residents and families from verifying the facility's daily staffing levels. This could result in distrust and a perceived lack of accountability in maintaining accurate and adequate staffing necessary for timely resident care. Findings: During an observation on 12/02/2025 at 9:30 AM, an untitled facility document was observed posted in the facility's front lobby. The document posted in the front lobby indicated the Facility Census was 30. The facility document indicated the nursing staffing information according to licensed nurses…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-04 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to follow safe and proper food storage practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to label and date food items and discard expired food inside the facility's kitchen. This failure had the potential to cause food-borne illness (illness caused by the ingestion of contaminated food or beverages) and adversely affect the health of the residents. Findings: During a concurrent observation and interview on 12/1/2025 at 8:43 with the Dietary Supervisor (DS) in the kitchen, the following were found: An opened five pounds (a unit of weight) container of sour cream with use by 11/30/2025 label on the lid inside the refrigerator. An opened unlabeled and undated two bags of carrots inside the refrigerator. A tray of unlabeled and undated individually prepared ice cream cups with a marking 11/19 on the clear plastic wrap covering the tray inside the freezer. An opened unlabeled and undated one gallon (a unit of volume) of corn oil under a…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-04 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) reviewed for resident's rights did not have Advance Directive (a legal document for stating medical wishes if one was unable to communicate) in resident's medical chart. This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident's wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: During a review of Resident 3's admission Record indicated the resident was admitted on [DATE] with diagnoses that included disorder of brain, cellulitis (a bacterial infection of the skin and the tissues beneath the skin) of right lower limb, and type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood) with diabetic neuropathy (nerve damage in people with diabetes). During a review of Resident 3's History and Physical (H&P), 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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, observation and record review, the facility failed to set the Alternating Pressure Mattress (APM, mattress that provides pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body are reduced) according to the resident's weight as indicated in the manufacturer's recommendation and physicians orders for one of one sampled residents (Resident 14) reviewed for pressure ulcer (skin injury due to prolonged unrelieved pressure or skin friction). Resident 14's mattress was observed set for 350 pounds (lbs.) while the resident weights 99lbs. This deficient practice had the potential for Resident 14 to develop worsened or new pressure ulcer or injury and/or delay the resident's wound to heal. Findings: During a review of Resident 14's admission Record (AR), the AR indicated the facility originally admitted Resident 14 on 5/10/2023 and most recently readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM2 - a condition…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-04 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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 interview and record review, the facility failed to ensure an assessment was completed and documented after dialysis (a treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to) for one of one sampled resident (Resident 7) reviewed for quality of care. This failure had the potential to put Resident 1 at risk for hypotension (low blood pressure [BP- the force of your blood pushing against your artery walls, like water in a hose]), bleeding, and access site (area on the body where the dialysis machine hooks up to the blood for dialysis) complications leading to hospitalization. Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 9/21/2022 and was readmitted on [DATE] with diagnoses that included but not limited to end stage renal disease ( ESRD - an irreversible kidney failure), heart failure (when the heart can't pump enough blood to meet the body's needs, leading to symptoms like shortness of breath,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1), who was unable to carry out activities of daily living (ADLs), received services to maintain good oral hygiene as indicated in the care plan by the certified nurse assistant (CNA) 1 after Resident 1 had been assisted and finished with his meal. This deficient practice had the potential to place Resident 1 at risk for diseases of the mouth, gums, and teeth, and aspiration (something other than air gets into your airways) of the food pieces in the mouth could further lead to pneumonia (an infection/inflammation in the lungs). Findings: During a review of Resident 1's admission Record (AR) the AR indicated that the facility originally admitted Resident 1 on 10/3/2024 and readmitted on [DATE], with diagnoses including metabolic encephalopathy (a series of neurological disorders result from systemic illness), dysphagia (difficulty swallowing), 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Dcited before2024-12-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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 a comfortable and homelike environment to one of thirteen sampled residents (Resident 2) by failing to provide the resident an extra blanket when the resident was cold at night. This deficient practice had the potential to expose the resident to an increased risk of hypothermia, discomfort, chills, worsening of existing medical conditions, and potential for skin breakdown from cold exposure. Findings: A review of Resident 2 ' s admission Record indicated that the facility admitted the resident on 3/16/2023 and readmitted the resident on 1/29/2024 with diagnoses that include generalized muscle weakness and depression (a serious mental health condition that can impact how a person feels, thinks, and acts). A review of Resident 45 ' s Minimum Data Set (MDS – a resident assessment tool), dated 11/18/2024, indicated that the resident ' s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was moderately impaired. During an interview 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-07 · tag F0576 — pattern
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    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 six of 6 sampled residents (Resident 28, 20, 21, 2, 5, and 81), received personal mails when delivered on Saturdays at the facility. This failure resulted in violating Resident 28, Resident 20, Resident 21, Resident 2, Resident 5, and Resident 81 rights to received mail on Saturdays which could result of missing important and timely correspondence. Findings: During an interview on 11/5/2024 at 10:00 AM, during Resident Council Meeting, Resident 28, Resident 20, Resident 21, Resident 2, Resident 5, and Resident 81 stated they received mail unopened on Monday through Friday but did not receive mails on Saturdays. During an interview on 11/5/2024 at 10:45 AM with the Business Office Manager (BOM), the BOM stated she was responsible for releasing the mail from Monday through Friday to Social Service Director (SSD-also was the Activity Director in the facility) or Activity Assistant. The BOM stated the SSD or Activity Assistant 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-07 · tag F0732 — pattern
    Post nurse staffing information every day.
    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 post an accurate facility staffing data in a prominent place where 32 of 32 residents and their representaives and visitors could easily view. This deficient practice had the potential to compromise the quality of care the residents receive due to potential insufficient staffing in the facility. Findings: During an observation on 11/04/24 at 04:28 PM, a staffing data dated 11/04/24 was posted to a wall behind the counter of the facility's nurse's station. The staffing data was not easily visible to read from the countertop in the nursing station that was approximately 10 feet away and was not accessible to the residents or visitors. During a concurrent review of the staffing data, the form indicated that the census was 41 for 11/04/24. A review of the facility's census dated 11/4/24 indicated that the resident census was 32. During an interview with the Director of Staff Development (DSD) on 11/06/24 at 01:07 PM, she stated that the staffing data that she posted on the wall at the Nurses Station 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Ecited before2024-11-07 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 2. During a review of Resident 27 ' s admission Record (Face Sheet), dated 10/23/2021, the face sheet indicated the facility admitted Resident 27 on 10/14/2024 with diagnoses including diabetes mellitus (elevated sugar in the blood), hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and history of falling. During a review of Resident 27 ' s History and Physical (H&P), dated 10/16/2024 indicated, Resident 27 had the mental capacity to make medical decisions. During a review of Resident 27's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 10/20/2024, indicated the cognitive (the ability to think and process information) skills for daily decisions making was severely impaired, and needed supervision to extensive assistance from the staff for the activities of daily living. During a concurrent interview and record review on 11/7/2024 at 11:15 AM, the Director of Nursing (DON) reviewed Resident 27 ' s Progress Notes 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-07 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow the facility ' s infection control policy and procedure for three of 3 sampled residents (Resident 11, 16, and 19) by failing to: Ensure that Enhanced Barrier Precautions (EBP-a set of infection control measures that use personal protective equipment (PPE) to reduce the spread of multidrug-resistant organisms (MDROs) were implemented by Certified Nursing Assistant (CNA 1, and 2 ) for three of 3 sampled Residents (Resident 11, 16, and 19) who all have indwelling catheter (a medical device that remains inside the body and provides a direct path for pathogens [any organism that causes disease] to enter the body and cause infection) and were at risk for Multi-Drug Resistant Organisms (MDRO, disease causing organism that have become resistant to certain antibiotics). These deficient practices had the potential to result in the spread of diseases and infections among the residents, visitors and staffs. Findings: During an observation on 11/4/2024 at 2 PM, a Stop sign on the door indicated all who enter 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the professional standard of practice and the facility ' s policy and procedure titled Emergency Management Codes and Procedures for medical emergency (Code Blue- is a hospital code to alert the facility staffs of a medical emergency) by failing to ensure: 1. Call Code Blue was announced on the facility ' s paging system when Resident 27 was found unresponsive to verbal stimuli and responsive to painful stimuli with decreased heart rate, respiratory rate, and blood pressure (the measurement of the pressure in the blood vessels when the heart relaxes or contracts the force of blood pushing against artery walls as the heart pumps blood throughout the body). 2. Cardiopulmonary Resuscitation (CPR-a lifesaving emergency procedure for a victim who has signs of cardiac arrest [a situation when a victim becomes unresponsive, no normal breathing, and no pulse]) was initiated immediately and not wait until full code (the patient required…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide pharmaceutical services as indicated in the facility's policy and procedure title Administering Medications for one of 3 sampled residents (Resident 27), who was administered Amlodipine (medication used to treat high blood pressure) when the resident ' s blood pressure was below the parameters (a fixed limit) set by the physician's order. These deficient practices had the potential to result in unintended complications such as dizziness, drowsiness, syncope (loss of consciousness) due hypotension (abnormally low blood pressure) that could lead to falls and injury. Findings: During a review of Resident 27 ' s admission Record, dated 10/23/2021, the face sheet indicated the facility admitted Resident 27 on 10/14/2024 with diagnoses including diabetes mellitus (elevated sugar in the blood), hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and history of falling. During a review of Resident 27 ' s History and Physical (H&P), dated 10/16/2024 indicated,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 the call light was in good functioning condition for one of sixteen sampled residents (Resident 23). This failure had the potential for Resident 23 not being able to call for assistance especially during emergency that could result in fall and injury. Findings: During a concurrent observation and interview on 11/4/2024 at 10:25 AM, in Resident 23's room, Resident 23 stated the call light system was not working then pressed the call light button to show the call light was not working. The call light did not make an audible sound and the call light above Resident 23's door did not turn on. During a concurrent observation and interview on 11/4/2024 at 10:45 AM with Certified Nursing Assistant (CNA) 1, in Resident 23's room, CNA 1 pressed the call light, but the call light did not make an audible sound and the light above Resident 23's door did not turn on. CNA 1 stated the call light was not working due to a loose plug on the wall,…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-19 · tag F0635 — isolated
    Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the facility ' s policy and procedure [P&P] titled admission Assessment and Follow Up: Role of the Nurse, for one of two sampled residents (Resident 1) when it failed to ensure all appropriate discharge orders from General Acute Care Hospital (GACH) 3 were verified with the attending physician (Physician 1) upon Resident 1 ' s readmission to the facility on [DATE]. This deficient practice could result in Resident 1 not receiving emergency medications such as Narcan (is a medicine that treat someone from fentanyl or prescription opioid medicine overdose) needed to treat opioid overdose. Findings: During a review of Resident 1 ' s GACH 3 records titled History and Physical dated [DATE], indicated [Resident 1] was found slumped [sitting with the body leaning forward, for example, because a person was asleep or unconscious] over in the wheelchair, then…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-19 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management 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 record review the facility failed to manage a resident ' s pain timely and effectively for one of two sampled residents (Resident 1), in accordance with the facility ' s policy and procedure titled Pain Assessment and Management, by failing to: 1. Follow the General Acute Care Hospital (GACH) 1 recommendations on pain management and the physician ' s order for Norco as needed for severe pain dated 9/9/2024. 2. Follow up with the pharmacy to ensure the ordered pain medication [Norco] was received and delivered timely. 3. Notify the physician when Resident 1 ' s pain management regimen was ineffective, and the resident received pain medication for mild pain [Ibuprofen], almost daily. 4. Update Resident 1 ' s Pain Care Plan to reflect specific resident-centered interventions needed to relieve the resident ' s pain. 5. Implement the facility ' s policy & procedure (P&P) titled Pain Assessment and Management that included monitoring for the effectiveness of interventions 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-19 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolated
    Have policies on smoking.
    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 the facility ' s policy and procedure (P&P) titled Smoking Schedule to ensure staff supervision during smoke breaks was implemented to provide safety for each resident during smoking, for one of three sampled residents (Resident 2) by failing to: Provide Staff supervision for Resident 2 during the facility ' s smoke break on 9/18/2024. Provide in-service to facility staff about the facility ' s Smoking P&P and smoking care plan for each resident who smokes. Ensure the facility maintained an updated list of resident smokers for reference. This deficient practice had the potential for Resident 2 and other resident smokers to be at risk for injury or burns without proper supervision and for the facility staff supervising not having the knowledge of what type of supervision are needed for each resident smoker. Findings: During a review of Resident 2 ' s admission Record indicated the facility admitted the resident on 9/9/2024, with diagnoses including chronic obstructive pulmonary disease (COPD – a common…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-12 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to promote and treat two of 2 residents (Resident 20 and 83) with respect, privacy and dignity by failing to ensure: 1. Resident 20's nephrostomy bag (a small flexible, rubber tube that is placed through your skin into the kidney to drain your urine) was covered to provide privacy. 2. Resident 83's privacy curtain was drawn close to provide privacy to the resident while Certified Nursing Assistant 1 (CNA 1) rendered care to Resident 83. These deficient practices had the potential to cause a psychosocial (mental and emotional well-being) decline, resident's individuality, self-esteem, and self-worth. Findings: 1. During a review of Resident 20's admission Record, indicated the facility admitted Resident 20 on 9/27/2022 with diagnoses that included chronic obstructive disease (COPD- a long-term exposure to irritants that damage the lungs and airways), epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-12 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each 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 provide reasonable accommodation of need for three of three sampled resident (Resident 9, 6 and 20) who was at risk for fall, by failing to ensure the residents call light (a device attached to the wall used by residents to call for assistance from the staffs) was within reach as indicated in the facility's policy and procedure, titled Answering the Call Light and resident's Care Plan. This deficient practice had the potential for the resident not to receive or received delayed care to meet the necessary care and services that could result in fall and accident. Findings: 1. During a review of Resident 9's admission Record, indicated the facility admitted Resident 9 on 9/21/2022 with diagnoses that included Parkinson's disease (an age-related degenerative brain condition that causes part of the brain to deteriorate causing slowed movements, tremors, balance problems and more) and lack of coordination. During a review of Resident 9's a 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-12 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure three (3) opened bottles of Enulose (also known as Lactulose-medication used to treat chronic constipation) solution stored in the medication cart which belonged to 3 of 3 residents (Resident 9, 8, and 21) were marked with the date that the bottles were first opened in accordance to the facility's policy and procedure for medication storage. This deficient practice had the potential to result in the loss of efficacy of medication due to unsafe storage of the medications. Findings: 1. During a review of Resident 9's an admission Record, indicated the facility admitted Resident 9 on 9/21/2022 with diagnoses that included Parkinson's disease (an age-related degenerative brain condition that causes part of the brain to deteriorate causing slowed movements, tremors, balance problems and more) and metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction (due to impaired cerebral metabolism). During a review…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-12 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 observation, interview, and record review, facility failed to follow the facility's policy and procedure titled Confidentiality of Information and Personal Privacy by ensuring the resident's identifiable, personal and medical information were not exposed on the computer screens and left unattended while in view of unauthorized persons and access two out of 2 residents (Resident 16 and 17) confidential information without the resident's consent or knowledge. This deficient practice resulted in Resident 16 and 17's violation of resident's right for privacy to keep their personal and medical records confidential and not readily observable and accessible by others. Findings: A review of Resident 16's Face Sheet (a document that gives a patient's information at a quick glance) indicated the facility admitted the resident on 9/7/2023 with diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system and the part of the body controlled by nerves), epilepsy (a brain condition…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-12 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide safe and sanitary environment to prevent the development and transmission of infections by ensuring the oxygen tubing or Nasal Cannula (NC-a device with two prongs inserted below the nose used to deliver supplemental oxygen directly into the nostrils or nares [opening of the nose]) was kept clean to prevent contact with disease causing organisms for for two of two residents (Resident 20 and 137) as indicated in the facility's policy and procedure by failing to ensure: 1. Resident 20's NC tube was not touching the floor. 2. Resident 137's NC was not touching the humidifier bottle (a bottle connected to the oxygen machine that moisturizes the air in the NC before breathing in the air) when not in use. These deficient practices had the potential for Residents 20 and 137 to contract infection when the NC when inserted into their nostrils which could increase the risk of the spread of infection to the residents, staff, and other…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to assess, monitor, inform the physician and provide necessary care and services in accordance with the facility's policy and procedure titled, Anticoagulation (medication for blood thinner) - Clinical Protocol and the resident's care plan for one (1) of one sampled resident (Resident 82), who was observed with bruises (skin discoloration due to bleeding underneath) while receiving Aspirin (a medication used to treat pain and reduce formation of blood clots). This deficient practice resulted in Resident 82's development of new bruises and skin tear that was undetected which could result in blood loss, infection and other side effects (unwanted effects of medication) and a decline in the resident's well being. Findings: During a review of Resident 82's admission Record, indicated the facility admitted Resident 82 on 11/7/2023 with diagnoses that included anemia (lack of red blood cells to carry adequate oxygen to the body's tissues) and myocardial infarction cerebral infarction (occurs because of disrupted blood…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-12 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to prevent unnecessary use of medication for one of one sampled resident (Resident 24) who was not monitored for bruising and bleeding while receiving Aspirin (acetylsalicylic acid [ASA], a medication used to treat pain and reduce formation of blood clots). This deficient practice increased the risk of Resident 48 to experience adverse effects (unwanted and dangerous side effects of medication) that could lead to health complications, such as bleeding and bruising in the intestines and stomach, other parts of the body. Findings: A review of Resident 24's admission Record indicated an admission to the facility on 8/14/2023 with diagnoses of contracture (condition of shortening and hardening of muscles, tendons, or other tissue) to right and left knee, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and transient cerebral ischemic attack (a stroke due to temporary blockage of blood flow to the brain). A review of Resident 24's History and Physical, dated 8/14/2023, indicated…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-12-04 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident area for fourteen (14) out of eighteen (18) resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 13, 14, 15, and 16). The 14 resident rooms consisted of 14 -two (2) bed capacity rooms. This deficient practice had the potential to impact the ability of the staff to provide safe nursing care and privacy to the residents. Findings: During an interview with the Administrator (ADM) on 12/1/2025 at 10:44 AM, the ADM stated the facility would like to request a room waiver (a document recording the waiving of a right or claim) this year. A review of the facility's letter to request for additional room waiver dated 12/1/2025 indicated the size of the rooms caused no negative outcome with regards to the health, safety, and welfare of all the residents in the facility. The request indicated the following resident bedrooms were: room [ROOM NUMBER] (2 beds) 2 residents…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2024-11-07 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for fourteen (14) out of sixteen (16) resident rooms (room [ROOM NUMBER],2,3,4,5,6,7,8,10,12,13,15 and 16). This deficient practice had the potential to negatively impact the quality-of-care and the ability of the nursing care to safely provide care and privacy to the residents. Findings: During the entrance conference interview with the Administrator (ADM) on 11/6/2024 at 9:06 AM, the ADM stated there were fourteen rooms (room [ROOM NUMBER],2,3,4,5,6,7,8,10,12,13,15 and 16) in the facility that did not meet the federal regulation [a regulation that the Long-Term Facilities was required to follow to meet federal requirement of by Centers for Medicare & Medicaid Services (CMS)] to ensure at least 80 square feet of space per resident in each room. The ADM stated the facility would like to request a room waiver (a document recording the waiving of a right 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2023-11-12 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident area for fourteen (14) out of eighteen (18) resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 13, 14, 15, and 16). The 14 resident rooms consisted of 14 -two (2) bed capacity rooms. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents. Findings: During an interview with the Administrator (ADM) on 11/11/2023 at 12:44 PM, the ADM stated the facility would like to request a room waiver (a document recording the waiving of a right or claim) this year. A review of the facility's letter to request for additional room waiver dated 11/11/2023 indicated the size of the rooms caused no negative outcome with regards to the health, safety, and welfare of all the residents in the facility. The request indicated the following resident bedrooms were: room [ROOM NUMBER] (2 beds) 2 residents 146.52 sq. ft.…

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

    Environmental Deficiencies · Deficient, Provider has date of correction

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

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

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

Fines & penalties

$13,627 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $13,627 — penalty dated 2024-09-19
  • Medicare payment denial — starting 2024-10-18 for 1 days

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 / managerTypeRoleShareSince
SB 2020 PROTECTIVE TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 03/01/2023
TB 2020 PROTECTIVE TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 03/01/2023
BHATIA, SONAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL50%since 03/01/2023
BHATIA, TANIAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER50%since 03/01/2023
GREAT NECK MANAGEMENT INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2015

CMS files one row per role, so the 10 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$5.5M
Net patient revenuemost recent cost report
-1.2%
Operating marginrevenue minus expenses
$1.2M
Related-party expense22% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 31%Other / private 1%

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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.

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

$479per resident / day
operating cost
$14,565per month
≈ monthly operating cost
$473per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555787. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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