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Almond View Care Center

1224 E Street, Williams, CA 95987 · For profit - Limited Liability company · 99 certified beds · (888) 309-0022 Medicare & Medicaid certified

Call the home — (888) 309-0022 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2026Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0744)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
717 Bridge St · (530) 458-2300 · Call to confirm hours
Pharmacy
692 E St
Grocery
 
Park
180 Virginia St · (530) 473-2955 · 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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
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 increased9.2%10.2%15.4%better
Long-stay residents who lose too much weight8.3%4.0%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection1.4%1.2%2.0%better
Long-stay residents with depressive symptoms2.5%7.3%6.5%better
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.2%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened8.6%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.8%13.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers0.3%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control24.0%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 table22.2%12.0%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.2%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine92.9%93.2%79.4%better
Short-stay residents rehospitalized after admission13.1%23.0%22.6%better
Short-stay residents with an outpatient ER visit7.7%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days1.622.251.67typical
Long-stay outpatient ER visits per 1,000 resident days0.841.571.80better

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.

30.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

30.6%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
64.0%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 64.0% 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 89 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 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 36% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF30.6%CMS range 19.5–45.251.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.5–14.310.7%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 discharge64.0%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 discharge48.3%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 discharge46.1%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 identified74.8%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 discharge88.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay4.2%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 worsened0.8%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 hospitalization6.5%CMS range 3.4–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.471.02Oct 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

0.29
RN hours/ resident / day
1.18
LPN hours/ resident / day
2.68
Aide hours/ resident / day
4.15
Total nurse hours/ resident / day
0.24
RN hoursweekends
49.1%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 99 beds and averages 96.9 residents a day — about 98% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.68 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 3.77 hrs/resident/day on weekends vs 4.30 on weekdays — 12% thinner on weekends. RN hours go from 0.31 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as 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

8
deficiencies at the latest standard inspection (2024-11-22)
2
at the previous standard inspection (2024-01-23)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Potential for harm · Ecited before2026-06-04 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect 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 ensure vulnerable demented residents were free from physical abuse and inappropriate sexual behaviors for 12 of 23 sampled residents when:1. Resident 8 was on top of Resident 7 with his genital (male private part) in her mouth.2. Resident 13 was holding Resident 23's hand over his penis and stroking it.3.Resident 11 was using his hand on Resident 14's hand to stroke his penis.4. a. Resident 4 struck Resident 11 in the face. b. Resident 4 grabbed Resident 1's wrist very aggressively. c. Resident 4 pushed Resident 6 to the ground. d. Resident 4 walked up to Resident 18 and pushed her forehead back. e. Resident 19 would not let go of Resident 4 hand then he grabbed Resident 19's arm. f. Resident 4 hit Resident 20 with his fist, on the left side of her forehead. g. Resident 4 swung to hit staff then struck Resident 21 instead, in the face. h. Resident 4 slapped Resident 22 and knocked her glasses off her face. 5. Resident 5 hit Resident 4 in the face…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-04 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 residents in the secured dementia unit (unit that is a specialized residential setting for individuals with Alzheimer's (a disease characterized by a progressive decline in mental abilities) or dementia (a progressive state of decline in mental abilities) that uses secured perimeters, such as locked exterior doors or fenced areas, to prevent wandering while maintaining a safe, structured environment) had sufficient and competent nursing staff and were available to provide nursing and related services to meet the residents' needs when:1 Acuity (complexity and intensity rather than just resident numbers) levels for dementia residents and increased resident altercations were not considered when scheduling Certified Nursing Assistants (CNA) staff in the secured dementia unit.2. Direct care staff did not receive specialized training for advanced stages of dementia.This resulted in vulnerable residents experiencing physical abuse,…

    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 · E2026-06-04 · tag F0865 — failed to run a quality-improvement (QAPI) program — pattern
    Have a plan that describes the process for conducting QAPI and QAA activities.
    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 have an effective Quality Assurance and Performance Improvement (QAPI) program, when the committee did not monitor, evaluate and track outcomes of a performance improvement plan to ensure sustainability to reduce resident to resident altercations in the secure dementia unit (a specialized residential setting for individuals with Alzheimer's (a disease characterized by a progressive decline in mental abilities) or dementia (a progressive state of decline in mental abilities) that uses secured perimeters to prevent wandering while maintaining a safe, structured environment).This resulted in repeated resident to resident altercations, injuries, nonconsensual sexual conduct, fear, and anxiety. Refer to F600 and F725. Findings:A review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI), implemented in September 2024, indicates that the facility will maintain an effective, comprehensive, data driven QAPI program that…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0641 — isolated
    Ensure 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 observation, interview, and record review, the facility failed to ensure that the Minimum Data Set (MDS, resident assessment tool) assessment was accurately coded for wandering behavior (the act of moving from place to place with or without a specified course or known direction) for one of three sampled residents (Resident 12) when the Social Services (SS) did not follow required assessment procedures, relied solely on chart review.This failure resulted in inaccurate assessment coding and failure to fully identify the resident's behavioral needs. It had the potential for staff not to be fully informed of the residents' health status to determine the need for further assessment and care interventions.Findings:During a review of the facility's policy titled, Resident Assessment - Resident Assessment Instrument (RAI), revised [DATE], indicated, The facility makes a comprehensive assessment of each resident's needs, goals, life history and preferences using the resident assessment instrument (RAI) specified…

    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 · F2024-11-22 · tag F0801 — widespread
    Employ 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

    Based on Observation, Interview, and Record Review the facility failed to ensure federal regulations related to the certification qualification requirement of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with resident assessment accuracy, meal distribution accuracy, safe food handling, and sanitation guidelines. Findings: According to the HSC 1265.4 (a) Shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. According to the HSC 1265.4, (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager…

    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 · E2024-11-22 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of Resident Council Minutes the facility failed to act promptly to resolve resident grievances in a timely manner and demonstrate their response and rationale for their response. This action had the potential to violate residents' rights. Findings: A review of a facility policy titled, Resident and Family Grievances dated 1/24/24, indicated grievances may be voiced verbally during resident or family council meetings. Under procedure, the policy included the following directions: The staff person receiving the grievance would record the nature and the specifics of the grievance. Steps would be taken to resolve the grievance, and record information about the grievance and actions taken on the grievance form. All staff involved in the grievance investigation should make prompt efforts to resolve the grievance. The Social Service Designee (SSD) would keep residents appropriately appraised of the progress and the resolution of the grievance. The SSD would issue a written decision on the grievance and a conclusion of the investigation. The facility would make…

    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 · E2024-11-22 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure the facility food was an appetizing temperature and palatable texture when 14 of 21 sampled residents (Residents 17, 9, 51, 70, 16, 36, 85, 72, 80, and five confidential residents), who received food prepared in the facility kitchen were not satisfied with the facility food temperature and texture. This failure had the potential to result in residents not obtaining appropriate nutritive intake, unplanned weight loss, increased health issue complications, and diminished emotional well-being. Findings: A review of the facility's policy and procedure (P&P) titled, Food Preparation Guidelines, dated February 2023, Revision, indicated, Food shall be palatable attractive, and at a safe and appetizing temperature. 1. A review of Resident 17's medical record indicated that Resident 17 was admitted on [DATE] with diagnoses that included Dementia with mood disturbance (loss of memory, language, problem solving, and thinking ability with mood issues such…

    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 · D2024-11-22 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide two out of eight sampled residents (Residents 80 and 92) with dignity and respect when: 1. Resident 80's bed was not made every day. 2. Resident 92 stated, facility staff spoke in a manner, that led her to believe, facility staff did not want to provide care to Resident 92 and had overheard staff talking disrespectfully about her just outside of the door. This failure had the potential to impact resident well-being and cause psychosocial harm. Findings: A review of the facility's policy and procedure (P&P) titled, Promoting/Maintaining Resident Dignity, dated 11/1/23, indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. The P&P indicated, staff would speak with respect and would have…

    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 · D2024-11-22 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents environment was clean, safe, comfortable, and homelike when: A drain in the kitchen was observed to have missing tile with exposed wood. Two tub and shower rooms used by residents were observed to contain excessive brown stains resembling rust on a handrail and on metal baskets used to hold soap and wash cloths. Doors in residents' rooms bathrooms were observed with scrapes, and gouges of exposed wood. One resident's wall next to his bed had multiple scrapes with exposed drywall. These findings had the potential for injuries to residents and an un home like environment. Findings: A review of a Safe and Homelike Environment policy dated 1/24/24 indicated the facility would provide a safe, clean and homelike environment to ensure residents can receive care and services safely. The policy additionally instructed that the facility maintenance and housekeeping would provide services as needed to maintain a safe, orderly, 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-22 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 report an allegation of abuse to the California Department of Public Health (CDPH) for one out of eight sampled residents (Resident 92) when Resident 92 notified Licensed Nurse (LN) A that facility staff working the night shift provided rough care (too much force, not careful or gentle). This failure had the potential for allegations of abuse to go unrecognized and placed residents at risk for abuse. Findings: A review of the facility's policy and procedure titled, Abuse-Reporting & Investigating, revised 11/1/16, indicated, when an allegation of abuse was made, the facility would notify CDPH. A review of the undated admission Record, indicated, Resident 92 was admitted to the facility on [DATE] with the diagnoses of hypertension (high blood pressure), anxiety (feelings of fear), and need for assistance with personal care (bathing, using bathroom, rolling in bed). Resident 92 was her own responsible party (made own decisions). A review of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Dcited before2024-11-22 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to include nail care to one sampled residents comprehensive care plan (Resident 8). Resident 8 was observed to have long dirty fingernails, and was observed eating with his fingers. This deficient practice led to unidentified need for nailcare, and the potential for injury (scratches), and poor hygiene. Findings: On 11/19/24 at 12:38 pm Resident 8 was observed eating his lunch in the Dining Room with his fingers. His nails on his fingers were observed long with black particles in the nails. A review of Resident 8's record indicated he was admitted to the facility on [DATE] with diagnoses that include dementia (a progressive state of decline in mental abilities), diabetes (disorder characterized by difficulty in blood sugar control and poor wound healinge), and the need for assistance with personal care. A review of a Minimum Data Set (MDS, an assessment tool) dated 8/30/24, indicated Resident 8 was severely impaired for decision making 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 · D2024-11-22 · 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 maintain personal hygiene to one sampled resident that was unable to carry out his activities of daily living (Resident 8). Resident 8 was observed to have long dirty fingernails. This deficient practice led to unidentified need for nailcare, and the potential for injury (scratches) and poor hygiene. Findings: On 11/19/24 at 12:38 pm, Resident 8 was observed eating his lunch in the Dining Room with his fingers. His nails on his fingers were observed long with black particles in the nails. A review of Resident 8's record indicated he was admitted to the facility on [DATE] with diagnoses that include dementia (a progressive state of decline in mental abilities), diabetes (disorder characterized by difficulty in blood sugar control and poor wound healinge), and the need for assistance with personal care. A review of a Minimum Data Set (MDS, an assessment tool) dated 8/30/24, indicated Resident 8 was severely impaired for decision making, 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 · D2024-11-15 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) dignity was honored when Certified Nursing Assistant C (CNA C) provided personal cares with the window covering open which exposed Resident 3 to an outside courtyard accessible to staff and residents. This failure had the potential to negatively affect Resident 3 ' s physical and mental well-being. Findings: A review of the facility ' s policy titled Promoting/Maintaining Resident Dignity dated 11/2023, indicated It is the practice of this facility to protect and promote residents ' rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident ' s quality of life by recognizing each resident ' s individuality. Compliance Guidelines 11. Maintain resident privacy. A review of Resident 3 ' s admission Record (undated) indicated that Resident 3 was admitted to the facility on [DATE] 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 · D2024-11-15 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 that one of four sampled residents (Resident 1) was free from physical restraints (any manual method, physical or mechanical device that the individual cannot remove easily that restricts movement or normal access to one ' s body) when a staff member (unknown) put two pillows under Resident 1 ' s mattress which tilted the mattress up and prevented him from getting out of bed. This failure had the potential for Resident 1 to be unable to move freely increasing the risk for the decline of physical functioning, injury, and mental harm from being restricted to his bed. Findings: A review of the facilities policy titled Restraint Free Environment dated 11/2023, indicated that It is the policy of this facility that each resident shall attain and maintain his/her highest practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience Falls do not constitute self-injurious behavior or a medical…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 residents received assistance devices to prevent accidents for two of four sampled residents (Resident 1 and Resident 2) when: 1. Staff did not ensure that Resident 1 had his call light (a bedside button that directly signals the nursing staff when a resident required assistance) and a urinal (a plastic container that a resident can urinate in while in bed or next to the bed) within reach per his fall prevention care plan. 2. Staff did not ensure that Resident 2 had anti-rollback brakes (a device that attaches to a wheelchair and locks the wheels when a resident stands up, preventing the chair from rolling away from the resident) on her wheelchair per her fall prevention care plan. These failures had the potential to place Resident 1 and Resident 2 at risk for falls and possible injuries. Findings: A review of the facility ' s policy titled Falls/Accidents dated 11/2023, indicated The resident will remain as free 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-26 · tag F0744 — failed to care for residents with dementia — pattern
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 develop and implement a care plan for one of three residents (Resident 2) that would prevent altercations with other residents, thus hindering the delivery of individualized dementia care needs. These failures have resulted in multiple resident to resident altercations with injuries and places this resident at high risk of further harm to others and self. Findings: During a review of the facility ' s policy, Care Plans, Comprehensive Person-Centered, revised 03/2022, indicated that the IDT team develops and implements a comprehensive, person-centered care plan, and the interventions come from thorough analysis of information gathered as part of the comprehensive assessment of the resident. These interventions are chosen with consideration of the relationship between the resident ' s problem areas and the causes, in alignment with clinical decision making. During a review of the facility ' s policy, Resident [NAME] of Rights, Title 22, Chapter IV, Part 483- Requirements For States And Long Term 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-26 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to ensure one of three residents (Resident 1) was free from abuse when another resident (Resident 2) pushed him down. This failure resulted in a rib fracture of Resident 1. Findings: During a review of the facility ' s policy and procedure, Resident-To-Resident Altercations, revised 11/16, indicated that the facility acts promptly and conscientiously to prevent and address altercations between residents. The purpose of this policy is to protect the health and safety of residents by ensuring that altercations between residents are promptly reported, investigated, and addressed by the facility. During a review of the facility ' s policy, Resident [NAME] of Rights, California Code of Regulations Title 22, Section 72527, Skilled Nursing Facilities, no date noted, indicated that patients have the rights detailed in these sections and the facility will safeguard that these rights are not violated. Paragraph (10) states, patients shall have the right to be free from mental and physical abuse. A review of a facility reported incident 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-23 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record reviews, and facility policy review, the facility failed to refer 2 (Resident #40 and Resident #55) of 4 sampled residents reviewed for preadmission screening and resident review (PASARR) when the resident received a new mental illness diagnosis. Findings included: Review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, implemented on 07/23/2023, revealed, This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder [MD], intellectual disability [ID], or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy specified, The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. Review of Resident #40's admission Record revealed the facility admitted the resident on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-23 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and facility policy review, the facility failed to ensure the accuracy of the preadmission screening and resident review (PASARR) level I screening for 1 (Resident #77) of 4 sampled residents reviewed for PASARR. Findings included: Review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, implemented on 07/23/2023, revealed, This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. A review of Resident #77's admission Record revealed the facility admitted the resident on 12/09/2023, with diagnoses that included bipolar disorder, major…

    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 before2021-07-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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, and interview, the facility failed to ensure that the resident environment remained free of accident hazards when the bathroom hot water temperature for numerous residents exceeded 120° degrees Fahrenheit (°F). This failure had the potential to result in burns for residents who had access to this hot water source, which could lead to pain, and negative clinical outcomes. Findings: The interpretive guidelines provided by the Centers for Medicare and Medicaid Services (CMS) indicated: Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition…

    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 · E2021-07-15 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure 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

    Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff were properly trained, and educated on hand hygiene during medication administration for four of eight sampled residents (Residents 68, 27, 33, and 26). This failure had the potential for residents to be at risk for cross contamination from dirty contaminated hands during medication pass, which could lead to negative clinical outcomes. Findings: The facility's policy and procedure titled, Specific Medication Administration Procedures, dated 3/4/14, was reviewed, and indicated that staff are to cleanse their hands using an antimicrobial soap and water, or facility approved hand sanitizer before having any contact with the residents. The facility's policy titled, Handwashing/Hand Hygiene, dated 2/28/17, was reviewed, and indicated that staff are to cleanse their hands using an antimicrobial soap and water, or facility approved hand sanitizer before and after direct resident care contact. Resident 68's medical record was reviewed. Resident 68 was admitted to this facility on 9/4/20,…

    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 · E2021-07-15 · 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 document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food services when several resident trays and plate covers were not allowed to dry fully before being stacked. This failure had the potential to result in bacteria growth and cause foodborne illness to residents who received food from these items. Findings: According to the Federal Food Code 2017, Section 4.901.11, after cleaning and sanitizing, equipment and utensils shall be air dried. During an observation, in the kitchen with the Registered Dietitian (RD), on 7/14/21 at 8:15 am, the Dietary Aide (DA) took several trays off the drying rack, and stacked them on a cart while they were still wet. She then took several plate covers off the drying rack and stacked them on a cart while they were still wet. The RD left and spoke with the Dietary Supervisor for a brief moment then returned. The RD confirmed that the items should have been completely dry before being stacked, and said all those items would be rewashed. On 7/15/21 at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the care plan was developed and implemented, for one of 21 residents (Resident 139), when the nutrition care plan was not updated to include a nutritional supplement, and adequate monitoring of that supplement. This failure had the potential to result in a decline in Resident 139's condition, including unintended weight loss, which could lead to negative clinical outcomes. Findings: Resident 139's medical record was reviewed. Resident 139 was admitted on [DATE], with diagnoses that included protein calorie malnutrition and dementia (degenerative disorder of the brain). Resident 139's admission weight was 95-pounds. The Diet Requisition, dated 7/10/21, included healthshakes with meals, three times per day. The care plan included, Diet as ordered, and Monitor meal consumption, but had not been updated to reflect the healthshake, and monitoring of the amount of healthshake consumed. During an observation, on 7/12/21 at 2:55 pm,…

    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 · D2021-07-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that outdated medication were removed from the medication cart, and disposed of per manufacturer's guidelines for one of eight sampled residents (Resident 11). This failure caused this resident to receive outdated medication for seven days, which had the potential to cause infection, or for the medication to longer be effective. Findings: The facility's policy and procedure titled, Medication Storage in the Facility, dated [DATE], was reviewed, and indicated that no expired medication are to be administered to a resident. Resident 11's medical record was reviewed. Resident 11 was admitted to this facility on [DATE], with diagnosis that included dementia (a degenerative brain disorder), and glaucoma (increased pressure in eyes). During a concurrent observation, interview, and record review, on [DATE] at 9 am, with Licensed Nurse (LN) 3, Latanoprost solution 0.005% eye drops (medication to control pressure in the eyes) was observed open 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-15 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one of 21 residents (Resident 20) was provided the specialized cup for meals, as ordered by his physician. This failure had the potential to result in swallowing difficulties which could cause aspiration (when liquids enter the airway), which could lead to negative clinical outcomes. Findings: Resident 20's medical record was reviewed. Resident 20 was readmitted to this facility on 6/17/21, with diagnoses that included obstructive uropathy (condition in which the flow of urine is blocked), heart disease, and dysphagia (difficulty swallowing). Resident 20's record contained a recommendation from the Speech Therapist (ST) on 6/21/21, to place Resident 20's food in bowls with a small spoon, and nectar thick liquids in a nosey cup (an adaptive drinking cup with a U-shaped cut-out on one side which provides space for the nose, allowing the user to tilt the cup for drinking without bending the neck or tilting the head) for all meals. This recommendation was signed by the physician as an order. Resident 20's…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to AJC HEALTHCARE — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.2+0.8 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 4 of 53.7+0.3 vs chain
The other 13 homes this chain runs (chain average 2.2★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
SWC CA OPCO 2 LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/01/2022
CHESLEY, AARONIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER50%since 03/01/2022
SILVAS, DEIDREIndividualW-2 MANAGING EMPLOYEEsince 03/01/2022
GAMETT, JAMESIndividualCORPORATE OFFICERsince 03/01/2022

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$16.9M
Net patient revenuemost recent cost report
+23.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 79%Medicare 19%Other / private 3%

About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

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

$365per resident / day
operating cost
$11,084per month
≈ monthly operating cost
$475per 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 555200. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-22, 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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