Northbrook Healthcare Center
64 Northbrook Way, Willits, CA 95490 · For profit - Limited Liability company · 70 certified beds · (707) 459-5592 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- it has an abuse, neglect, or exploitation citation (F0604), cited Mar 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- 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
- the CMS record shows $9,295 in federal fines (most recent 2025-03-05)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.1% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.0% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.7% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 15.1% | 7.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.9% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 11.5% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.0% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.3% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.0% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.4% | 10.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.4% | 12.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 69.2% | 93.2% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 9.6% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.7% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.00 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.83 | 1.57 | 1.80 | better |
‡ 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.
55.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 80 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.7% 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 62 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 0.66 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 37% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.6%CMS range 46.0–64.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 6.9–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 67.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 75.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 95.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.8%CMS range 3.2–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 70 beds and averages 38.3 residents a day — about 55% occupied, or roughly 32 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 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 3.61 hrs/resident/day on weekends vs 4.21 on weekdays — 14% thinner on weekends. RN hours go from 0.40 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2025-03-05 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure 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 one resident (Resident 1) of four sampled residents was free from physical abuse when two Certified Nursing Assistants (CNAs) intentionally held down Resident 1 against his will while performing perineal care (the cleaning and maintenance of the genital and anal areas). This failure resulted in Resident 1 feeling belittled and upset. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE] with a diagnosis of pleural effusion (abnormal buildup of fluid between the lungs and the chest wall). A review of a care plan, initiated on 2/19/25, indicated Resident 1 had an activities of daily living self care performance deficit related to generalized weakness. In order to assist Resident 1 to safely perform grooming, toilet use, and personal hygiene, staff were to conduct the following interventions, [For] toilet use .[Resident 1] requires assistance to .clean self, transfer onto toilet, transfer off toilet,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-01-30 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure that food was prepared by methods that preserved nutrition and palatability when three residents (Resident 20, Resident 26, Resident 30) out of 38 residents received meals that were flavorless, difficult to chew and overcooked.This failure decreased the facility's potential to serve food to residents with nutritive content and decreased the residents' potential to maintain or increase their meal intake with food served by the kitchen.Findings:During a concurrent interview and observation in Resident 26's room on 1/28/26at 8:30 a.m., Resident 26 complained about the potatoes he was served for breakfast. The cubed potatoes noted on his plate were pale in color. Resident 26 stated the potatoes were too difficult for him to chew because the potatoes were still raw in the center. Resident 26 was observed trying to cut one of the cubed potatoes with a fork and was noted to have difficulty doing so. Resident 26 stated the potatoes served in this fashion were usually hard and were inedible. Resident 26 further…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-01-30 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure that food was stored, prepared and served safely in accordance with professional standards of food service when:Clean plastic cups were stored in soiled, heavily scratched plastic racks and food crumbs were observed under a layer of dirty plastic netting which clean eating utensils were stored on top of in a utensil tray; and,The front of the facility stove was stained with old grease drippings while the stovetop was encrusted with hardened black residue; and,Cook 1 failed to maintain proper hand hygiene during meal prep and trayline when he repeatedly contaminated his gloves by touching his personal clothing and other kitchen items before handling food products; and,Refrigerated items found with no use by date.These failures posed the risk for food borne illness for 38 residents for a census of 38 residents that resided in the facility and consumed food prepared in the kitchen.Findings:1. During a concurrent observation and interview in the facility kitchen on 1/27/26 at 9:56 a.m., clean plastic cups…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-01-30 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain an environment free of pests for 38 residents for a census of 38 when two flies were observed in the kitchen during food preparation.This failure decreased the facility's potential to prevent foodborne illnesses among residents.Findings:During a concurrent observation and interview in the kitchen on 1/28/26 at 10:55 a.m., two flies were observed flying around the area where lunch was being prepared. The Certified Dietary Manager (CDM) confirmed the presence of flies in the kitchen. The CDM stated the flies may have come in with someone when they entered the building from the outside. There was no electronic air curtain noted upon entry to the facility.A review of the facility's policy titled Pest Control, dated February 2025, indicated, It is the policy of this facility to utilize pesticides.in a safe and efficient manner to control pests.The following are guidelines for pest prevention.All storage and food preparation areas are to be kept clean. This includes.equipment.A review of the FDA 2022 Food Code…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-01-30 · tag F0806 — failed to honor food preferences — patternEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 food preferences were honored for four residents (Resident 10, Resident 30, Resident 41, Resident 26) of 38 sampled residents when the residents were served meals which contained food they disliked.This failure decreased the facility's potential to serve food that met residents' nutritional needs.Findings: During a concurrent observation and interview in the facility dining room on 1/27/26 at 12:31 p.m., Resident 10 and Resident 41 were eating their lunches. This surveyor observed both residents' plates contained untouched peas. Resident 10 stated she did not like peas and Resident 41 stated she had never liked peas and was confused as to why they were placed on her tray. A review of their meal tray tickets indicated both Resident 10 and Resident 41 disliked peas. During a concurrent observation and interview on 1/27/26 at 1:09 p.m., Resident 30 was eating lunch in her room. Resident 30 stated, I will not eat the peas they served…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 develop and implement care plans for two residents (Resident 20, Resident 21) of four sampled residents when Licensed Nurses (LN) did not:Initiate a care plan for Resident 20's need for oxygen therapy; and,Implement interventions indicated in Resident 21's care plan regarding the risk of skin impairment.These failures decreased the facility's potential to communicate Resident 20's care needs regarding oxygen therapy among facility staff and resulted in Resident 21 sustaining a wound to her left lateral (a side of the body positioned away from midline) upper calf.Findings:1. A review of Resident 20's admission record indicated admission to the facility on 1/1/26 with a diagnosis of Heart Failure (a chronic disease where the heart cannot pump enough blood to meet the body's needs, often causing fluid buildup in the lungs or body).A review of Resident 20's physician orders dated 1/1/26, indicated, O2 [oxygen] 1 LPM [Liters per…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 3) of four sampled residents was properly groomed and had her call light within reach when Resident 3 was observed to have uncombed hair, dirty fingernails, and fecal matter (bowel movement) on her pillowcase, sheets and bedside table, and had no way to call for assistance.This deficiency decreased the facility' potential to ensure Resident 3 received personal care to maintain adequate hygiene.Findings:A review of Resident 3's admission record indicated admission on [DATE] with diagnoses of esophageal obstruction (blockage of the tube leading from the throat to the stomach), need for assistance with personal care, muscle weakness, and repeated falls. A review of Resident 3's care plan, initiated on 10/1/25, indicated Resident 3 was at risk for falls. Staff were expected to Be sure the call light is within reach and encourage to use it to call for assistance as needed to decrease her risk of falling.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.
- Potential for harm · Dcited before2026-01-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was clean and in a usable state for one resident (Resident 20) out of four sampled residents when in Resident 20's oxygen concentrator had visible dust and debris in the vents.This failure decreased the facility's potential to prevent bacteria and debris from directly entering Resident 20's lungs, placing her at risk for infection.Findings:A review of Resident 20's admission record indicated Resident 20 was admitted to the facility on [DATE] with a diagnosis of Heart Failure (a chronic disease where the heart cannot pump enough blood to meet the body's needs, often causing fluid buildup in the lungs or body).A review of Resident 20's physician orders dated 1/1/26, indicated, O2 [oxygen] 1 LPM [Liters per minute-indicates how much oxygen will be delivered per minute] via NC [nasal cannula-a flexible device used to deliver oxygen through the nose].A review of Resident 20's MDS (Minimum Data Set- a federally…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-29 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide medications as ordered by the prescriber, when two residents (Resident 1 and Resident 2) of three sampled residents received their medications late on two days.This failure decreased the facility's potential to prevent serious health consequences including worsening symptoms, disease progression, and increased risk of complications.Findings:A review of Resident 1's admission record, dated 12/19/25, indicated Resident 1 was admitted with diagnoses that included trigeminal neuralgia (a chronic pain condition causing sudden, severe, electric shock-like pain in the face, affecting the trigeminal nerve) and syndrome of inappropriate secretion of antidiuretic hormone (a condition that causes excessive water retention in the kidneys).During a concurrent interview and record review on 12/20/25 at 3:10 p.m. with the Director of Nursing (DON), Resident 1's Medication Admin Audit Reports dated 12/20/25-12/21/25 were reviewed. The report indicated Resident 1 had the following medications scheduled for 12/20/25 and 12/21/25 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.
- Potential for harm · D2025-04-10 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5 percent (%) or less. There were 3 errors out of 43 opportunities, which resulted in a medication error rate of 6.98 % for 2 (Resident #2 and Resident #4) of 5 residents observed during medication administration. Findings included: A facility policy titled, Administration Procedures For All Medications, dated 05/2022, indicated, C. Review 5 Rights (3) times: 1) Prior to removing the medication package/container from the cart/drawer; a. Check MAR/TAR [medication administration record/treatment administration record] for order. b. Note any allergies or contraindications the resident may have prior to drug administration. c. If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information. d. Check for vital signs, other tests to be done during/prior to medication administration. e. Prepare resident for medication administration. 2) Prior to removing the medication from the container a. Check…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-10 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility document and policy review, the facility failed to ensure medication administration records accurately reflected the medications administered for 1 (Resident #27) of 5 residents reviewed for unnecessary medications. In addition, the facility failed to ensure medication orders were correctly transcribed into the electronic health record (EHR) for 1 (Resident #2) of 5 residents observed during medication administration. Findings included: 1. A facility policy titled, Administration Procedures for All Medications dated 05/2022, revealed, J. After administration, return to the cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR [Medication Administration Record] or TAR [Treatment Administration Record]. An admission Record revealed the facility admitted Resident #27 on 01/17/2025. According to the admission Record, the resident had a medical history that included diagnoses of gout and chronic kidney disease. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · F2023-03-27 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure discontinued medications were removed from stock according to facility policy and procedure (P&P), medications were appropriately labeled with a pharmacy label identifying which resident they were for, and expired medications were not available for resident use. The deficient practices had the potential to result in medications being administered not in accordance with physician's order and residents receiving medications with unsafe or reduced potency from being used past their discard date. Findings: On 3/20/23 at 11:14 a.m., an inspection of the Medication Storage Room alongside Licensed Nurse 1 (LN 1) identified two Mounjaro (an injectable medication used to treat diabetes) 2.5 milligram/0.5 milliliter (mg/ml, a unit of measurement) pens. One pen was inside a clear bag with a pharmacy label on the outside for Resident 4. The second pen was unlabeled with a pharmacy label and was not in any other packaging identifying which resident it was for. LN 1 stated all medications should have a pharmacy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-03-27 · tag F0801 — widespreadEmploy 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 food production observation, dietary staff interview, and dietary document review, the facility failed to ensure a Registered Dietician (RD) was overseeing the operations of the facility's Food Service Department and a qualified Dietary Supervisor or fulltime RD was overseeing the day-to-day operations of the kitchen, and evaulating dietary staff for competencies (cross reference F 812). These failures resulted in issues with safe and effective food storage, meal production (cross reference F 804) correct therapeutic diets being plated (cross reference F803) and infection control (cross reference F 812). Failure to ensure adequate oversight may result in compromising the nutritional status of all residents and cross contamination of resident food and foodborne illness. Findings: During the initial tour of the kitchen on 3/20/23 at 11:20 a.m. there was no Dietary Supervisor overseeing the kitchen. The Rehabilitation Manager stated she was overseeing the kitchen. The Rehabilitation Manager stated the Dietary Supervisor was on the way. A review of the facility job descriptions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-03-27 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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 dietary observation, interview, and dietary record review, the facility failed to ensure staff possessed required competency as evidenced by dietary staff members were not: 1) following recipes for a.spinach and b. meatloaf 2) following therapeutic diets when a. portion sizes were not plated correctly, meat needing to be pureed (texture-modified diet with the consistence of pudding for people who have difficulties with chewing and swallowing) was not weighed properly, and b.mash potatoes were not fortified 3) qualified to oversee the day-to-day operations of the kitchen and 4) qualified to evaluate cooks for competences. Failure to ensure staff competency could result in decreased food distribution and food production systems to ensure food palpability and nutritional content, which could result in decreased dietary intake that did not meet individual resident nutritional requirement. This could result in weight loss and further compromise resident medical status. Findings: 1a) During an observation 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.
- Potential for harm · F2023-03-27 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to prepare a meal tray with 1) the individual therapeutic portion size for 30 out of 33 residents, when 30 residents' meatloaf portion size was not followed per the residents' lunch meal card, and 2) 13 out of 13 residents on a Fortified diet did not have their mash potatoes fortified with one oz of gravy per Spring 2023 Week 3 Fortified Lunch. These failures to ensure nutritional content could result in decreased dietary intake and resulted in less calories and protein, which may result in weight loss and further compromise resident medical status. Findings: 1) During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10 a.m., there was six pounds of hamburger to serve 30 residents. The Garden Fresh Meatloaf recipe indicated six pounds of hamburger would serve 24 residents. [NAME] B stated there was one vegetarian, two residents who did not like beef, and thirty residents who would be having the hamburger either in the form of meatloaf or a hamburger patty. When…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-03-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on kitchen observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by 1) frozen vegetables were not sealed, 2) dietary staff did not know quaternary (quat ammonium compounds designed to kill germs) wet time for sanitizer solutions, 3) cook did not sanitize countertop after preparing meat, and 4) the cook was not wearing appropriate aprons for cooking and washing cooking utensils and equipment per the facility's policy/procedure. Failure to ensure effective dietetic services operations may result in placing residents at risk for foodborne illness as well as bacterial and foreign object contamination resulting in gastrointestinal distress, weight loss and in severe instances may result in death. Findings: 1. During the initial tour of the kitchen on 3/20/23 at 11:20 a.m. the frozen corn and frozen peas located in the freezer in the main kitchen area were both stored in unsealed blue bags, which were in open cardboard boxes. During a concurrent observation and interview on 3/22/23 at 8:40 a.m., the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-03-27 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to designate a qualified staff member to function in the role of Infection Preventionist (IP) (individual responsible for the facility's activities aimed at reducing the spread of disease by collecting and analyzing data on healthcare-associated infections, identifying outbreaks, and using appropriate prevention strategies to prevent and control further spread), per the facility's assessment plan. This failure created potential for inability to implement programs and activities to prevent and control infections in a population of vulnerable residents, which placed 33 of 33 Residents at risk for infections. Findings: During an interview on 03/22/23 at 12 p.m., the Director of Nursing (DON) and Licensed Nurse A (LN A) were asked about the IP at the facility. The DON stated the IP had quit working at the facility approximately five to six weeks earlier. During and interview on 03/22/23 at 4:01 p.m., the DON stated the facility did not have a full-time IP Nurse, as the prior IP nurse left her position at the facility in early…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-03-27 · tag F0919 — failed to provide a working call system — widespreadMake 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 and interview, the facility failed to ensure the call light system was accessible to residents while lying on the floor in the restrooms for residents in 19 of 21 rooms. This failure created the potential for residents, who fell while using the restroom, from activating the call light system and summoning help. Findings: During an observation and interview on 3/22/23, at 8:50 a.m., with the Director of Maintenance (DM), the restrooms used by residents in 19 of 21 rooms (Rooms 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 17, 19, 20, 21, 2, 23, 24 and 25) were inspected. All the restrooms had the call light button located next to the toilet at elbow level from a resident sitting on the toilet. There was no string or cord from the call light button reaching the floor. The DM measured the height of the call light button in all restrooms and stated it was 36 inches from the floor. During a simulation of a fall from the toilet in the restroom used by residents in rooms [ROOM NUMBERS], it was not possible…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-27 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for two out of three residents (Resident 8 and Resident 26) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications. Findings: The controlled medication CDR for three random residents receiving as needed controlled medications were requested for review during the survey. During an interview on 3/21/23, at 9:44 a.m., with Licensed Nurse 2 (LN 2), LN 2 stated whenever a controlled medication was administered to a resident, the dose was to be documented in both the CDR and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-27 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on food production observation, dietary staff and resident interview, and dietary record review, the facility failed to ensure meals were prepared and served in a manner to maintain palatability and nutrient content as evidence by: 1) holding time for Penne pasta, green beans, and turkey and gravy was over 1 hour prior to the beginning of meal service, 2) frozen spinach was cooked on the stovetop for over two hours prior to placing on the steam table, 3) recipes were not followed, 4) two out of 12 Sampled Residents (Resident 2 and Resident 33) and three Unsampled Residents (Resident 1, Resident 4, and Resident 86) did not like the food and/or had issues with the temperature of the food, the texture of food items, quality of the food or taste of the food, and 5) test tray evaluation of noon meal tray on 3/22/23 at 1 p.m. found to have meat that was dry, lacked flavor and greasy tasting, spinach needed seasoning/lacked flavor, mashed potatoes were bland, and pureed meat and spinach were cold. Failure to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-27 · tag F0865 — failed to run a quality-improvement (QAPI) program — patternHave 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
Based on interview and record review, the facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program addressed the full range of care and services provided by the facility when a dietary department representative participated in only three of the previous 12 QAPI meetings. This failure had the potential for the facility to neglect dietary quality deficits. Findings: During an interview and record review on 3/24/23, at 1:26 p.m., the Administrator stated the facility's Quality Assurance and Performance Improvement (QAPI) committee met monthly to review and address quality issues in the facility. The Administrator stated all department heads attended the QAPI committee meetings. The Administrator provided the attendance sheets of the past 12 QAPI committee meetings, held on 2/28/23, 1/25/23, 12/22/22, 11/30/22, 10/27/22, 9/28/22, 8/30/22, 7/28/22, 6/22/22, 5/26/22, 4/28/22 and 3/23/22. A review of the attendance sheets of the above 12 meetings indicated a representative from the dietary department only attended three of the meetings: on 2/28/23, 1/25/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-27 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when a glucometer was not disinfected in accordance with facility policy and procedure (P&P) and manufacturer's specifications after resident use. This failure had the potential to result in the development of infection and transmission of bloodborne diseases (such as HIV [human immunodeficiency virus, a virus that attacks the body's immune system], Hepatitis B, and Hepatitis C). Findings: During an observation on 3/20/23, at 12 p.m., with Licensed Nurse 2 (LN 2), LN 2 was observed testing Resident 4's blood sugar using an Assure Platinum glucometer. He inserted the test strip into the glucometer, poked the resident's finger with a lancet, placed a drop of Resident 4's blood on the test strip, and allowed the glucometer to measure the blood sugar level. Once the reading was complete, LN 2 disposed of the test strip and returned to the medication cart with the glucometer. LN 2 then used an alcohol prep pad to wipe down the glucometer. During an interview 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.
- Potential for harm · D2023-03-27 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure its policy and procedure on abuse prevention indicated required time frames for reporting allegations of abuse, neglect, misappropriation of resident property, or exploitation to the Department, as well as the need to submit the facility's investigative report of such allegations to the Department, and the required time frame to do so. These failures had the potential for untimely reporting of abuse, neglect, misappropriation of resident property, or exploitation to the Department and failure to submit the respective investigative reports to the Department, thereby hindering the Department's investigation of the allegations. Findings: A review of facility policy and procedure titled Abuse: Prevention of and Prohibition Against, revised 01/2021, under section titled REPORTING/RESPONSE, indicated: Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported . to the appropriate State and Federal agencies in the applicable timeframes . and A summary of investigative findings…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-27 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to hold quarterly care conferences for one of three residents (Resident 16). This failure prevented Resident 16's Responsible Party to be involved in Resident 16's care plans. Findings: A review of Resident 16's facesheet indicated he was admitted to the facility on [DATE] and had a Responsible Party (RP) (a person responsible for making healthcare decisions on behalf of the resident). During an interview on 3/21/23, at 10:50 a.m., Resident 16's RP stated she had not been invited to attend care conferences for Resident 16. Resident 16's RP stated she would like to participate in Resident 16 care conferences. During an interview on 3/24/23, at 9:35 a.m., the Director of Nursing (DON) stated the facility's policy was to have resident care conferences upon admission and quarterly thereafter or upon a change in condition. The DON stated the resident, or their responsible party, were invited to participate in the care conferences. During a concurrent record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-27 · tag F0847 — isolatedInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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 three residents (Resident 12) who signed arbitration agreements understood the agreement when Resident 12 was cognitively impaired when he signed the agreement. This failure resulted in Resident 12 agreeing to something he did not understand. Findings: During an interview and record review on 3/22/23, at 10:05 a.m., the Business Office Manager (BOM) stated she was responsible for offering and explaining the facility's arbitration agreement to residents. The BOM stated residents were offered arbitration agreements during the admission process. The BOM stated Resident 12 had signed an arbitration agreement upon admission and provided the agreement. A review of the agreement indicated it was signed by Resident 12 himself on 10/27/22, which was confirmed by the BOM. During an observation and interview on 3/22/23, at 10:18 a.m., Resident 12 was in his room and was asked if he knew what an arbitration agreement was and if he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$9,295 in federal fines across 1 penalty.
- $9,295 — penalty dated 2025-03-05
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.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.2 | +1.8 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GAMBLE, SHAWNDEE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/15/2001 |
| RAO, SEEMA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2024 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | since 01/30/2006 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | since 03/01/2011 |
| WILLITS, ADAM | Individual | CORPORATE OFFICER | since 09/09/2024 |
| TWOMAGNETS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2002 |
| PORT, BARRY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/11/2025 |
| CARETRUST GP LLC | Organization | ADP OF THE SNF | since 11/15/2001 |
| CARETRUST REIT INC | Organization | ADP OF THE SNF | since 11/15/2001 |
| CTR PARTNERSHIP LP | Organization | ADP OF THE SNF | since 11/15/2001 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | since 11/15/2001 |
| WILLITS HEALTH HOLDINGS LLC | Organization | ADP OF THE SNF | since 11/15/2001 |
CMS files one row per role, so the 17 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
6 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.
About 76% 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. This home reported $575K paid to related parties — landlords or management companies under common ownership — equal to about 12% 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 056215. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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