Cedar Mountain Post Acute
11970 4th St, Yucaipa, CA 92399 · For profit - Limited Liability company · 99 certified beds · (909) 790-2273 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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.
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 | 8.1% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.4% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.8% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.0% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 9.4% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 29.2% | 13.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.1% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 2.5% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.4% | 12.0% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.5% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.0% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.8% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.73 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.25 | 1.57 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.5% 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 43 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 19.1% 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 21 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 0.68 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 19% 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 | 47.5%CMS range 32.7–65.0 | 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 | 10.7%CMS range 6.8–16.1 | 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 | 19.1% | 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 | 9.5% | 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 | 19.1% | 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 | 97.8% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.4%CMS range 4.8–13.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.28 | 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 99 beds and averages 94.1 residents a day — about 95% occupied, or roughly 5 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 4.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.43 hrs/resident/day on weekends vs 4.74 on weekdays — 6% thinner on weekends. RN hours go from 0.64 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Dcited before2026-04-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their own policy regarding safety and supervision for one of three sampled residents (Resident 1) when Resident 1 had a fall incident during a transfer to a shower chair on March 14, 2026. This failure may have potentially contributed to Resident 1 sustaining acute mildly displaced fracture of the proximal tibia and proximal fibular shaft (a recent break in the upper neck of the knee and the thin shin bone). Findings: A review of Resident 1's admission RECORD indicated Resident 1 was last admitted to the facility on [DATE], with diagnoses of hemiplegia (a condition of not being able to move one side of the body) hemiparesis (a condition of weakness on side of the body affecting arms and legs, aphasia (a condition of not able to speak) and age-related cataract (a condition of the eye). A review of Resident 4's History and Physical dated, February 20, 2026, indicated, . OTHER PLAN: . Patient [Resident 1] is not able to make own decisions.A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-16 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate care and services, which were consistent with the resident's needs and choices, for residents who are unable to carry out Activities of Daily Living (those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) independently for one of three sampled residents (Resident 1) when Resident 1, who was dependent for self-care and mobility, was repositioned by a Certified Nursing Assistant (CNA 1) in bed by himself, dishonoring Resident 1's Wife's preference for Resident 1 for a two-person assist (safe patient handling technique in healthcare where two trained caregivers help someone move, transfer, or perform daily activities when they can't do it alone). This failure resulted in Resident 1 to fall out of bed, posing a potential risk to Resident 1's health and safety.Findings: A review of Resident 1's face sheet…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-25 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate assessment for one of four sampled residents (Resident 12) when the Minimum Data Set (MDS- a standardized assessment tool) assessment did not reflect the accurate status of Resident 12 who was receiving hospice (end of life care) services.This failure had the potential for unmet services necessary for Resident 12's hospice care.Findings:A review of Resident 12's admission Record, dated 9/26/25, indicated Resident 12 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD- a progressive lung disease which blocks air flow making breathing difficult) and cirrhosis of the liver (scarring of the liver, caused by chronic injury or long-term liver disease) among others.A review of the facility document titled, Order Entry, a physician's order for Resident 12, dated 7/8/2025, indicated, May admit to (Name of company) Hospice under (name of physician) Dx (abbreviation for diagnosis):…
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 · D2025-11-25 · 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 comprehensive and person-centered care plans for one of one sampled resident (Resident 25) when:a. There was no care plan addressing anticoagulant (medication that helps prevent blood clots) use for Resident 25.b. The facility did not implement injury prevention interventions identified in Resident 25's fall risk care plan.These failures had the potential to result in complications from anticoagulant therapy and injury from falls for Resident 25.Findings:a. A review of Resident 25's admission Record, indicated Resident 25 was readmitted to the facility on [DATE] with diagnoses including Unspecified Atrial Fibrillation (Afib - an irregular heartbeat that commonly causes poor blood flow).A review of Resident 25's Minimum Data Set (MDS- a standardized assessment tool), dated 8/15/25, indicated Resident 25's cognitive (ability to think and reason) skills for decision making were intact. The MDS indicated Resident 25 had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 17, Resident 22, and Resident 25) were free from accident hazards when:a. The wheelchair arm rests for Resident 22 were peeled off with abrasive fragments and exposed cushion.b. Floor mats were not provided as ordered for injury prevention interventions for Resident 17. c. Floor mats were not provided as ordered for injury prevention interventions for Resident 25.These failures had the potential to compromise the safety of Residents 22, 17, and 25 and result in skin breakdown, accidents, and injuries.Findings: a. A review of Resident 22's admission Record, indicated Resident 22 was admitted to the facility on [DATE], with diagnoses that included cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), diabetes (a long term condition that causes high blood sugar levels), and paraplegia (loss of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-25 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dental services, including the timely provision and replacement of dentures, were provided to one of one sampled resident (Resident 84).This failure had the potential to result in impaired nutrition, oral pain and discomfort, difficulty eating, and decreased quality of life for Resident 84.Findings:A review of Resident 84's admission Record (a document containing a summary of basic information about the resident), indicated Resident 84 was admitted to the facility on [DATE] and readmitted to the facility on [DATE].A review of Resident 84's Minimum Data Set (MDS- a standardized assessment tool), dated 9/10/25, indicated Resident 84's cognitive (ability to think and reason) skills for decision making were intact. The MDS indicated Resident 84 had no natural teeth.A review of Resident 84's Treatment Sheet, dated 6/19/25, indicated a Treatment Plan including a referral for new dentures.A review of Resident 84's Care Plan titled Dental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-25 · 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
Based on observation, interview and record review, the facility failed to implement infection prevention and control practices to provide a safe and sanitary environment to help prevent the transmission of spreadable diseases and infections when:1. One gray basin was found on the bathroom floor containing four food containers and two utensils.2. Respiratory Therapist 1 (RT 1) did not do hand hygiene after stepping out from Resident 58's room and after removing gloves.3. Three resident trash bins were full and overflowing.These deficient practices posed the risk for transmission of communicable diseases and infections to residents in the facility. Findings: 1. During an observation on 9/22/25, at 9:15 AM, in the bathroom between the rooms of Resident 6 and Resident 20, a gray basin containing food containers and utensils was found on the floor. During a concurrent observation and interview with Certified Nurse Assistant 1 (CNA 1), on 9/22/25, at 12:55 PM, CNA 1 was asked about the contents of the gray bin and stated there were four food containers and two forks. CNA 1 stated this was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-09 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility staff failed to notify the physician for one of three sampled residents (Resident 2) when: 1. Resident 2 had twenty-four episodes of high blood pressure (blood pressure higher than 160) and were not reported to the doctor. This failure had the potential to cause Resident 2 to suffer complications. 2. Resident 2 had eight episodes of high blood sugars and were not reported to the doctor. This failure had the potential to cause Resident 2 to suffer complications. Finding: During a review of Resident 2's admission Record (contains demographic and medical information) dated, August 21, 2023, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included Diabetes Mellitus (high blood sugar) and Hypertensive Heart Disease (A condition of the heart caused by high blood pressure). During a review of Resident 2's Medication Administration Record (MAR) dated August 1, 2023, through August 30, 2023, it indicated, Hydralazine HCL (medication used…
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 before2023-03-16 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow proper sanitation and food safety practices to prevent foodborne illnesses as evidenced by food debris, black grime and dirt were observed under the kitchen stove and griddle. This failure had the potential to result in food contamination and foodborne illnesses to medically compromised population of 71 of 94 residents in the facility. Findings: During a concurrent observation and interview with the Kitchen [NAME] (KC 1) on March 13, 2023, at 8:35 AM, there were food debris, black grime and dirt seen under the kitchen stove and griddle. The KC 1 stated the floor should be kept clean and free from debris and dirt. During an interview with the Dietary Service Supervisor (DSS) on March 14, 2023, at 3:15 PM, the DSS stated they had designated staff assigned each day for mopping and sweeping the kitchen floor. The DSS stated the kitchen floors should be kept clean, otherwise it could potentially attract insects and rodents which could contaminate food. During a concurrent interview and record review with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-16 · tag F0641 — isolatedEnsure 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 accurately code the status of a pressure injury (a wound developed on bony prominences as a result of prolonged pressure) in the Minimum Data Set (MDS - a computerized clinical assessment) for Resident 31. This failure had the potential to inaccurately reflect Resident 31's status to the oversight agency (Center for Medicare and Medicaid Services - CMS), who provides funding for Resident 31. Findings: During a review of Resident 31's clinical record, the face sheet (contains admission and demographic information), indicated Resident 31 was admitted on [DATE], with diagnoses which included chronic respiratory failure (long term dysfunction or complications of the lungs), intestinal obstruction (a condition in which digested material is prevented from passing normally through the bowel), and chronic kidney disease (long term dysfunction or complications of the kidneys). Upon further review of the clinical record for Resident 31, 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.
Show the remaining 13 citations
- Potential for harm · D2023-03-16 · tag F0644 — isolatedCoordinate 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to submit an updated Preadmission Screening and Resident Review (PASRR - a federal screening requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) after a diagnosis of Schizophrenia (a serious mental illness that affects how a person think, feels, and behaves, and is often characterized by symptoms of visual or auditory hallucinations) had been identified after admission for Resident 78. This failure had the potential for Resident 78 not to be accurately assessed by a qualified mental health professional, in order to ensure proper placement related to his mental illness. Findings: During a review of Resident 78's clinical record, the face sheet (contains admission and demographic information) indicated the resident was admitted on [DATE], with diagnoses which included acute necrotizing hemorrhagic encephalopathy (a central nervous…
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 · D2023-03-16 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 identify mental disorders during the Preadmission Screening and Resident Review (PASARR-a screening to identify the presence of serious mental illness) for one of one sampled resident (Resident 61). This failure had the potential to cause Resident 61 not to receive specialized mental health services. Findings: A review of Resident 61's face sheet (a document that gives a summary of resident 61 information), undated, indicated Resident 61 was admitted to the facility on [DATE], with a diagnosis of schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear). A review of Resident 61's PASARR dated November 5, 2022, indicated, .Result of Level I Screening: Level I - Negative, . Reason Code: No Serious Mental Illness. Section III - Serious Mental Illness - Definition: 10. Does the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-16 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide services to maintain and improve one of one sampled resident (Resident 36) ability to communicate her needs to the facility staff. This failure had the potential to cause Resident 36's needs to go unmet resulting in frustration, pain, and discomfort. Findings: A review of Resident 36's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 36 was admitted to the facility on [DATE], with diagnoses that included: amyotrophic lateral sclerosis (ALS-a nervous system disease that weakens muscles and impacts physical function), quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and dependence on respirator/ventilator (dependent on mechanical ventilation). During an observation and interview with Resident 36 on March 13, 2023, at 8 AM, Resident 36 was unable…
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 · D2023-03-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 36) was repositioned every two hours to promote healing of Resident 36's Stage IV pressure sore (an injury caused by prolonged pressure that is very deep, reaching into muscle and bone). This failure had the potential to cause Resident 36's Stage IV pressure sore to worsen or additional pressure sores to develop. Findings: A review of Resident 36's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 36 was admitted to the facility on [DATE], with diagnoses that included: amyotrophic lateral sclerosis (ALS-a nervous system disease that weakens muscles and impacts physical function), quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and dependence on respirator/ventilator (dependent on mechanical ventilation). A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide adequate supervision and a valid assistance device (fire extinguisher) to prevent accidents when: 1. Resident 50 was found smoking on the outside patio without one-to-one supervision. This failure had the potential for Resident 50 to have a smoking accident. 2. A fire extinguisher's inspection tag had expired, and the fire extinguisher was mounted in the smoking area for use. This failure had the potential for residents to be exposed to injuries for outdated equipment. Findings: During an observation on [DATE], at 1:30 PM, Resident 50 was seen smoking unsupervised on the outside patio under the rain. During an interview on [DATE], at 1:39 PM, with Resident 50, Resident 50 stated they have been smoking unsupervised for a long time. During a review of Resident 50's Face Sheet, (contains demographic information), undated, indicated Resident 50 was admitted on [DATE], with a diagnosis to include cerebral infarction (disrupted blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide the necessary respiratory care when a Physicians order for Oxygen therapy was not followed for one of three residents (Resident 59). This failure had the potential for resident 59 to experience shortness of breath. Findings: During an observation on March 13, 2023, at 11:40 AM, in Resident 59's room, Resident 59 was receiving 4 Liters (L) (Liters= unit of measurement) of oxygen via nasal cannula (a tube placed in the nose to deliver oxygen). During a review of Resident 59's medical record, Face Sheet (contains demographic information), undated, indicated Resident 59 was admitted on [DATE], with a diagnosis to include Chronic Obstructive Pulmonary Disease (COPD-lung diseases that block airflow and make it difficult to breathe). During a concurrent observation and interview on March 13, 2023, at 12:00 PM, with Licensed Vocational Nurse (LVN1), LVN 1 was observed checking the amount of oxygen Resident 59 was receiving. LVN 1 stated…
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 · D2023-03-16 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 78's clinical record, the face sheet (contains admission and demographic information) indicated Resident 78 was admitted on [DATE], with current diagnoses which included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, and is often characterized by symptoms of visual or auditory hallucinations). Further review of the clinical record indicated the resident had a current physician's order for Seroquel Oral Tablet 50 mg [milligram - unit of measurement] .Give 1 tablet by mouth two times a day for schizophrenia m/b [manifested by] auditory hallucinations . During a concurrent observation and interview on March 13, 2023, at 8:22 AM, Resident 78 was observed lying in bed, mumbling, and talking to himself. No one else was at his bedside at the time. When interviewed, Resident 78 was able to engage in simple conversation and answer questions but was noted to be very easily distracted and talkative about details not pertaining to the original…
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 · D2023-03-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor antipsychotic medication for effectiveness and adverse [harmful] side effects for one of one sampled resident (Resident 12). This failure had the potential to cause ineffective control of symptoms to go unrecognized and unaddressed. In addition, Resident 12 had the potential to suffer prolonged adverse side effects of the medication. Findings: A review of Resident 12's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 12 was admitted to the facility on [DATE], with a diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs.) A review of Resident 12's physician's order dated February 23, 2023, indicated, Risperidone [an antipsychotic medication to treat bipolar disorder] Oral Tablet 3 [three] MG [milligrams-a unit of measurement] Give 1 [one] tablet via G-Tube [a tube inserted through the wall of the abdomen directly into 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 · D2023-03-16 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist with dental services needed for one of six sampled residents (Resident 196). This failure prevented Resident 196 from obtaining an identified need for dental services. Findings: In a review of Resident 196's face sheet (a document containing basic information, demographics, and diagnoses), indicated Resident 196 was self-responsible and was admitted to the facility on [DATE]. A review of Resident 196's physician order, dated February 16, 2023, indicated, Dental evaluation and treatment as indicated. During a concurrent observation and interview with Resident 196 on March 13, 2023, at 4:23 PM, Resident 196 was seen inside his room, observed with missing entire upper teeth and some lower teeth. Resident 196 stated he came to the facility with the same oral condition, but no one had approached him about dental services. Resident 196 further stated he could use dentures but was not made aware the facility could arrange for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-16 · 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 practice infection prevention and control in accordance with their policy for one of six sampled residents (Resident 73) when a foley catheter (a flexible tube that a clinician passes through the bladder) drainage bag was observed touching the floor. This failure had the potential to cause catheter-associated complications including urinary tract infection for Resident 73. Finding: During record review of Resident 73's face sheet (a document containing basic information, demographics and diagnoses), indicated Resident 73 and was admitted to the facility on [DATE], with a diagnosis of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it.) During a concurrent observation and interview with the Infection Preventionist (IP) on March 15, 2023, at 8:05 AM, Resident 73's urine drainage bag was observed touching the floor. The IP stated the drainage bag should not touch…
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 before2019-12-06 · 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 an opened bag of carrots in the walk-in refrigerator was dated, labeled, and sealed. This failure had the potential to cause food-borne illnesses for 86 out of 88 residents in the facility who received food from the kitchen and were a medically vulnerable resident population. Findings: During a concurrent observation and interview on December 2, 2019 at 8:20 AM, with the Dietetic Services Supervisor (DSS), a bag of unsealed carrots was observed in the walk-in refrigerator which was not dated and not labeled. The DSS acknowledged the bag of carrots was not dated, labeled, or sealed. During a review of the facility's policy on General, Receiving of Delivery of Foods and Supplies Section 6.3 (undated), the policy indicated, Label all items with the delivery date or use-by date. During a review of another facility policy on Storing Produce Section 6.14, Number 8 (undated), the policy indicated When storing vegetables should remain crisp .they will stay fresh longer if you place them in a sealed bag or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-06 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise the care plan for one of one sampled resident (Resident 11) to address repeated non-compliance with the facility's smoking policy. This failure had the potential to result in Resident 11 placing herself, other residents and staff at risk of injury from a possible fire. Findings: During a concurrent observation and interview on December 2, 2019, at 11:23 AM, with Resident 11, in Resident 11's room, she stated she smokes unsupervised and that she keeps her cigarettes and lighter in her room. Resident 11 revealed her cigarettes and lighter that were stored in the cup holder of her wheelchair in her room. During a review of Resident 11's smoking assessment dated [DATE], the smoking assessment indicated that 8 d. Resident is safe to smoke independently and 9. Facility to store lighter and cigarettes? 1. Yes (marked) During a concurrent observation and interview on December 2, 2019, at 3:47 PM, with a Licensed Vocational Nurse (LVN 1),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision to address one of one sampled resident (Resident 11) repeated non-compliance with the facility's smoking policy. This failure resulted in a risk of fire and had the potential to put residents and staff at risk for harm. Findings: During a concurrent observation and interview on December 2, 2019, at 11:23 AM, with Resident 11, in Resident 11's room, she stated she smokes unsupervised and that she keeps her cigarettes and lighter in her room. Resident 11 revealed her cigarettes and lighter that were stored in the cup holder of her wheelchair in her room. During a review of Resident 11's smoking assessment dated [DATE], the smoking assessment indicated , .8 d. Resident is safe to smoke independently and 9. Facility to store lighter and cigarettes? 1. Yes (marked) During a concurrent observation and interview on December 2, 2019, at 3:47 PM, with a Licensed Vocational Nurse (LVN 1), Resident 11 observed to be in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to MADISON CREEK PARTNERS — 13 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 | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 4 of 5 | 3.0 | +1.0 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 3 of 5 | 4.1 | -1.1 vs chain |
The other 12 homes this chain runs (chain average 3.2★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CEDAR OPERATIONS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/13/2015 |
| CHRISTENSEN, COVEY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/13/2015 |
| CLEGG, MICHAEL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/26/2023 |
| MADISON CREEK PARTNERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/13/2015 |
| DALTON, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2022 |
| HAGE, JEAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2012 |
| HOPKINS, AMBER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2021 |
CMS files one row per role, so the 15 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 555494. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-25, 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.