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Yucaipa Hills Post Acute

13542 2nd St., Yucaipa, CA 92399 · For profit - Limited Liability company · 82 certified beds · (909) 795-2421 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Oct 20241 immediate-jeopardy citation$31,899 in federal fines1 Medicare payment denial
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $31,899 in federal fines (most recent 2024-10-18)
  • its facility-reported quality-measure 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
13391 California St # 1 · (909) 795-9747 · Call to confirm hours
Pharmacy
1186 Calimesa Blvd · (909) 795-1147 · Call to confirm hours
Grocery
34078 County Line Rd · (909) 795-9208 · Call to confirm hours
Park
960 4th St · (909) 795-9801 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased20.7%10.2%15.4%worse
Long-stay residents who lose too much weight4.3%4.0%5.4%better
Long-stay residents with a catheter left in their bladder1.2%0.8%0.9%worse
Long-stay residents with a urinary tract infection2.7%1.2%2.0%worse
Long-stay residents with depressive symptoms0.4%7.3%6.5%better
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.1%1.6%3.3%typical
Long-stay residents whose ability to walk worsened13.8%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.0%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine97.5%98.2%95.3%typical
Long-stay residents with pressure ulcers6.0%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control22.1%10.2%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table4.7%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine72.5%93.2%79.4%typical
Short-stay residents rehospitalized after admission20.1%23.0%22.6%better
Short-stay residents with an outpatient ER visit17.6%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.252.251.67worse
Long-stay outpatient ER visits per 1,000 resident days2.531.571.80worse

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.

39.6% 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 49 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

39.6%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
21.1%U.S. median 56.6%
Met the expected recovery
0.38U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy

Met the expected recovery: 21.1% 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 57 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF39.6%CMS range 27.6–54.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.1–16.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge21.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge26.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge24.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting87.8%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.9%CMS range 3.6–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.561.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.27
RN hours/ resident / day
1.05
LPN hours/ resident / day
2.54
Aide hours/ resident / day
3.86
Total nurse hours/ resident / day
0.15
RN hoursweekends
44.4%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 82 beds and averages 78.6 residents a day — about 96% occupied, or roughly 3 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 3.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.27 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 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 3.56 hrs/resident/day on weekends vs 3.98 on weekdays — 11% thinner on weekends. RN hours go from 0.32 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

6
deficiencies at the latest standard inspection (2026-01-08)
9
at the previous standard inspection (2024-10-18)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-10-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY An immediate jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents on October 16, 2024, at 4:53 PM, regarding the elopement of Resident 27 from the facility on October 16, 2024. An IJ was called in the presence of the Administrator. A corrective action plan was requested on October 16, 2024, at 4:53 PM. The immediate Jeopardy was removed after the corrective action plan was verified to be implemented through observations interviews, and record reviews on October 17, 2024, at 2:46 PM in the presence of the Administrator. Free of Accident Hazards / Supervision/Devices CFR (s): 483.25(d)(2)(2) §483.25 (d) Accidents. The facility must ensure that. §483.25(d)(1) The resident environment remains as free of accidents hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-09-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one on one (1:1) supervision (direct one on one monitoring of a resident by a staff member) was implemented for one of 80 residents (Resident 1) as ordered by a physician on April 13, 2023 when Resident 1 was found on the floor of his room with his door closed and unaccompanied by staff with a laceration (a cut or skin wound) injury to his head after he sustained an unwitnessed fall. This failure resulted in Resident 1 sustaining a head injury which required treatment and evaluation in a hospital. Findings: During a review of Resident 1 ' s clinical record, the admission Record (contains demographic and medical information), indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses which included diffuse traumatic brain injury (head injury), dementia (a brain disease that causes memory disorders, personality changes, and impaired reasoning), unsteadiness on feet, epilepsy (a brain disorder that causes recurring…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-08 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one of two crash carts (a wheeled cart carrying emergency equipment and medications for use in case of emergency) were checked and documented daily by staff as per facility's policy and procedure (P&P) titled, Emergency Medical supplies and equipment when the crash cart in the upper unit (CCUU) was not checked and documented. This failure had the potential to cause delay in availability and functionality of emergency equipment and medications in case of an emergency which will impact the health and safety of all residents in the facility.Findings:During a concurrent observation and interview on January 7,2026, at 11:00 AM, with Infection Preventionist nurse (IP), the facility's crash cart in the upper unit (CCUU) was checked and observed to have missing signatures for the following dates:July 1, 2025, through July 31, 2025 (31 days on night shift were missing signatures)August 6, 2025, and August 7, 2025 (2 days on night shift were missing signatures)August 15, 2025 (PM shift was missing…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-08 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 follow their policy and procedure (P&P) for Foods brought by family/visitors when one of 6 sampled residents (Resident 47) reviewed for nutrition received food from a visitor of another resident. This failure had the potential to compromise dietary compliance and risk Resident 47's health and nutritional needsFindings:During an observation on January 7, 2026, at 12:45 PM, in activity/dining room, Resident 47 was sitting on table one with other residents . One of the resident's (Resident 19) wife (not a resident in the facility/visitor) brought snacks including potato chips, marshmallows, a packet of hot [NAME] powder (a package of powder which contains chocolate and sugar and can be mixed with water or milk to make hot chocolate) were handed by the visitor to Resident 47. Resident 47 opened the packet and put some powder on his desert, and swallowed the remaining powder directly. It was also observed that the visitor was offering potato…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 observation, interview, and record review, the facility failed to follow policy and procedure (P&P) titled, Oxygen Administration, for one out of one sampled resident (Resident 7) when oxygen was not administered according to the physician's order. This failure had the potential to compromise Resident 7's respiratory status which would risk resident 7's health and well-being.Findings:During a concurrent observation, and interview, on January 6, 2026,at 10:26 AM, with Infection Preventionist Nurse(IP) in Resident 7's room, Resident 7 was lying on bed with eyes closed. Resident 7 had nasal canula (a clear plastic tube through which the oxygen is delivered to the nostrils) which was connected to oxygen on her face but the nose piece (the opening where the oxygen is delivered to the patient) was away from Resident 7's nostrils. The IP stated, the oxygen was not on Resident 7's nose and she might have pulled that out. The IP acknowledged that nurses are responsible for checking the placement and delivery 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-08 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety when there was visible accumulation of grime and debris within an actively used oven and the continued presence of a non-functional refrigerator in the food preparation area. This failure had the potential to result in accumulating pathogenic microorganisms (germs or infectious agents that can cause disease) and to attract insects or rodents, which could place the health and safety of 81 highly vulnerable residents who receive food from the kitchen at risk.Findings:During a concurrent observation on January 5, 2026, at 7:57 AM, with the Dietary Supervisor (DS), an initial tour of the kitchen was conducted. A non-functional refrigerator, labeled out of order was observed in the kitchen food preparation area. The DS stated, the refrigerator had been non-operational for approximately two weeks and was not being used. The refrigerator continued to take up space in the kitchen and had not been relocated to another area.During a…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective infection control practices for one of 18 sampled residents (Resident 6) when an indwelling urinary catheter (Foley-a tube that stays inside the bladder to drain the urine into a bag) drainage bag was observed resting on the floor.This failure had the potential to promote the transmission of infection by allowing contamination of the urinary catheter drainage system and increasing the risk of urinary tract infection. Findings: A review of Resident 6's face sheet (FS- a document with resident demographics, brief medical history, and emergency contacts), the FS indicated, Resident 6 was admitted on [DATE] with diagnoses which included urinary tract infection (UTI-an infection in the bladder or urinary system that can cause pain, burning, frequent urination, fever or confusion), neuromuscular dysfunction of the bladder (the nerves and muscles that control the bladder do not work properly, making it difficult to urinate…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the prevention of avoidable accidents for one of three sampled residents (Resident 1) when Resident 1, a resident who was at high risk for falls and fully dependent upon staff for mobility while in bed, fell from his bed while being changed by Certified Nursing Assistant 1 (CNA 1). This failure resulted in Resident 1 to sustain a head injury which included a bleeding laceration to his right eyebrow and a subarachnoid hemorrhage (bleeding in the area between your brain and the thin tissues that cover and protect it). Findings: During a review of Resident 1's admission Record (contains medical and demographic information), the record indicated Resident 1 was admitted on [DATE], with diagnoses which included cerebral palsy (neurological disorder that causes permanent problems with movement, balance, and posture), parkinson's disease (a disorder of the central nervous system that affects movement), disorders of bone density and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-18 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 a Minimum Data Set (MDS- a facility assessment tool that consists of the resident assessment instrument (RAI) and the care area assessment (CAA) was conducted and submitted to the Centers of Medicare and Medicaid Services (CMS) in accordance with federal submission timeframes, for thirteen of thirteen residents (Residents 54, 55, 15, 27, 35, 40, 47, 49, 51, 62, 63, 66, and 76) reviewed for residents' assessment. These failures resulted in inadequate monitoring of progress or decline for Residents 54, 55, 15, 27, 35, 40, 47, 49, 51, 62, 63, 66, and 76 and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: A. During a review of Resident 54's admission Record, (contains demographic and medical information), the admission Record, indicated Resident 54 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), psychosis (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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eighteen residents (Resident 36) reviewed for advanced directives had a Physician Orders for Life Sustaining Treatment (POLST - written medical orders that addresses a limited number of critical medical decisions) accurately completed when there was conflicting information documented regarding medical interventions. This failure had the potential for Resident 36 to receive end of life care not in accordance with their wishes and for life sustaining measures to be rendered against what the resident wanted. Findings: During a review of Resident 36's admission Record, (contains medical and demographic information), the admission Record indicated Resident 36 was initially admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis on one side of the body) affecting left non-dominant side, heart failure, chronic respiratory failure (a long-term condition that prevents 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure staff reported an allegation of abuse to the required parties and in the timelines specified by the facility's policy and procedures (P&P) and as required by federal regulations. This failure resulted in an allegation of abuse to not be reported and subsequently investigated which had the potential to place Residents 36 at risk for ongoing abuse or mistreatment due to a delay in the reporting and investigation of the alleged incident. Findings: A review of Resident 36's admission Record (contains medical and demographic information), indicated Resident 36 was initially admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis) affecting left non-dominant side, heart failure, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (a condition that…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two residents (Residents 14 and 11) received care and services as specified In their care plans (individualized plans for the medical care of a resident) when: 1) For Resident 14, the facility did not ensure staff kept the resident's smoking materials. This failure had the potential to result in in accident or injury to Resident 14 and other residents residing in the facility as a result of increased fire hazard. 2) For Resident 11, the facility did not ensure staff checked the residents blood sugar before meals. This failure has the potential to affect Resident 11's blood sugar management and could lead to inaccurate blood sugar readings, which may result improper insulin administration (medication use in the treatment and management of diabetes) and increased risk of hyperglycemia (elevated blood sugar). Findings: 1) During a review of Resident 14's clinical record, the admission Record (contains medical and demographic…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · D2024-10-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor and document the low air loss mattress (specialized mattress designed to help prevent and treat pressure ulcers) according to the physician's order for one of two sampled residents (Resident 40) who had a pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This failure had the potential for Resident 40 not to receive the necessary treatment and services. Findings: A review of Resident 40's admission Record, (contains demographic and medical information), indicated Resident 40 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and epilepsy (a disorder of the brain characterized by repeated seizures). During an observation on October 15, 2024, at 8:36 AM, Resident 40 was observed in her room, laying on her left side and asleep on a low air loss mattress…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 document a gradual dose reduction (GDR) for one of eight sampled residents (Resident 55) when a recommended a decrease in Trazadone (a medicine that helps people who are feeling very sad or having trouble to sleep) from 100 mg (milligrams unit of measurement) to 50 mg was not done and documented. This failure has the potential to result in over medication and increased risk of side effects for Resident 55. Finding: During a review of Resident 55's admission Record (contains demographic and medical information), indicated Resident 55 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (a mental health condition characterized by persistent sadness and loss of interest), and bipolar disorder (a mental health condition where a person has extreme mood swings). During a review of Resident 55's pharmacist's recommendation dated October 7, 2024, indicated a recommended GDR of Trazadone dose from 100 mg…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-18 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) for labeling and dating of food items when a bottle of [brand name] creamer was found on top of a table inside the kitchen at room temperature without an open date. This failure has the potential to increase the risk of foodborne illness or contamination due to improper storage practices. Finding: During an observation on October 14, 2024, at 8:16 AM, during a tour inside the kitchen area, a bottle of [brand name] coffee creamer was observed on top of a table inside the kitchen area. The bottle was open and halfway already used, and there was no open date written on the bottle to indicate when it was first opened. During an interview on October 14, 2024, at 8:18 AM, with the Dietary Services Supervisor, (DSS 1), the DSS 1 confirmed that the creamer was found open, used and unlabeled. The DSS 1 stated that the bottle of creamer should be labeled and properly stored according to facility's P&P. The DSS 1 further stated that the bottle of creamer will be dispose immediately.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-18 · tag F0912 — isolated
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 46 resident's rooms (rooms [ROOM NUMBERS]) had the required 80 square feet (Sq Ft - unit of measurement) of space for each resident. This failure had the potential to limit freedom of movement and affect the health and safety of four residents (Resident 55, 28, 64, and 44) who reside in the two rooms. Findings: During an interview with the Administrator (ADMIN) on October 17, 2024 at 8:11 AM, the ADMIN stated the facility has two rooms with square footage waivers, rooms [ROOM NUMBERS]. The ADMIN further stated the facility submitted a room waiver variance sometime within the last week. During concurrent observations, and interviews with the residents (55 and 28) in room [ROOM NUMBER], on October 17, 2024 at 8:13 AM the following were observed: Bed 7A was occupied by Resident 55, who was observed resting comfortably in bed. Resident 55 did not verbalize any issues or concerns with the size of the room. There were no concerns…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-26 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow a system for controlling the spread of a communicable disease for one of four sampled residents (Resident 1) when Resident 1 was on transmission-based droplet precautions (a set of measures used to prevent the spread of organisms that cause disease through respiratory secretions) for a coronavirus disease (COVID-19-an infectious disease caused by a virus) exposure and was allowed to participate in activities with 11 other residents. This failure had the potential to cause the spread of COVID-19 to other residents in the facility. Findings: A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admission date of March 8, 2024. Resident 1 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 5 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admission date of February 22, 2024. Resident 5 had diagnoses…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-18 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe environment for two of three sampled residents (Residents 1 and 3) when: 1. Resident 1 ' s call light was found hanging from a light fixture on a wall. 2. Resident 3 ' s call light was found behind a nightstand on the floor. These failures had the potential to result in resident harm and unmet needs for Residents 1 and 3. Findings: 1. During a review of Resident 1 ' s admission Record (contains demographic and medical information), the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of dementia (a condition where a person experiences a decline in their memory, thinking and reasoning skills), unsteadiness on feet, and repeated falls. During a concurrent observation and interview, on March 12, 2024, at 10:19 AM, with Resident 1, in her room, Resident 1 ' s call light was hanging from the light fixture on the wall, inaccessible. Resident 1 stated she did not know where the call light…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedures for Fall Risk Assessment for one of three sampled residents (Resident 1) when Resident 1 was not accurately assessed for fall risk. This failure resulted in Resident 1 to experience a fall. Findings: An unannounced visit was made to the facility on November 30, 2023, at 5:30 PM, to investigate a Facility Reported Incident (FRI) regarding quality of care/treatment. During an observation on November 30, 2023, at 5:35 PM, in Resident 1's room, Resident 1 was lying down on her bed on her back, with head of the bed elevated. Resident 1 had a bandage wrapped around her leg and heel protector on feet. During an interview on November 30, 2023, at 5:45 PM, in Resident 1's room, Resident 1 stated she did not remember when she had a fall. During a review of Resident 1's face sheet (a document which contain basic information about the resident) indicated Resident 1 was admitted to the facility on [DATE], with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-08 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the privacy of one of 86 residents (Resident 1) who resided within the facility when a staff member recorded a video of Resident 1 (while inside the facility's dining room) and posted the video on a personal social media platform without Resident 1's approval or consent. This failure resulted in a violation of Resident 1's right to privacy and confidentiality as well as a breach of the Health Insurance Portability and Accountability Act law (HIPPA -a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge). Findings: During a review of Resident 1's admission Record (contains Resident 1's medical and demographic information), undated, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included Unspecified Dementia (a brain disease that causes memory disorders, personality changes, and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-02-24 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure 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 ensure the lunch menu was being followed on February 21, 2023, when: 1. Six residents on a Pureed Diet (texture modified diet where all foods are blended to a mashed potato consistency) received a half-cup serving of Chicken Jambalaya (meat and rice dish), when the menu indicated a one-cup serving of Chicken Jambalaya should have been provided. 2. 62 Residents on a Regular Diet (diet that does not include any meal restrictions), Mechanical Soft Diet (altered-texture diet for people who have difficulty chewing and swallowing), and a CCHO Diet (consistent carbohydrate - diet indicated for people with diabetes mellitus, a disease that alters how the body processes sugar) received the wrong meal portion of Chicken Jambalaya. The residents on these diets received a two-thirds cup of Chicken Jambalaya, when the menu indicated a one-cup serving of Chicken Jambalaya should have been provided. 3. One resident on a Finger Food Diet (diet to be eaten using fingers) received a bowl of rice, when they should have received…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-24 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food prepared for residents on a Pureed Diet (texture modified diet where all foods are blended to a mashed potato consistency) was palatable for lunch on February 22, 2023, when five out of five residents (Resident 4, 56, 28, 27, and 25) on a Pureed Diet were served pureed meatloaf that was not palatable and did not taste comparable to the meatloaf that was served to the residents receiving a Regular Diet (diet with no restrictions). This failure had the potential to cause the residents on a Pureed Diet to experience a decrease in food intake which could lead to poor nutrition and health outcomes for these vulnerable residents in the facility. Findings: During a concurrent interview and meal taste test of the lunch that was served on February 22, 2023, at 1:06 PM, at Nursing Station 1, with Registered Dietitian 2 (RD 2), sample trays of the Regular Diet and Pureed Diet were tested for palatability, appearance, texture, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-24 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 food in a form that met individual needs when 28 of 28 residents on a Mechanical Soft Diet (altered-texture diet for people who have difficulty chewing and swallowing) were served toasted bread with crust when the menu indicated they should have received soft bread with no hard crusts. This failure had the potential for the affected residents to choke and/or aspirate (accidental breathing of food or fluid into lungs) with the restricted food forms, which could have resulted in resident harm. Findings: During an observation on February 21, 2023, at 12:05 PM, in the facility kitchen during the plating of the residents' lunches, [NAME] 1 served the residents on a Mechanical Soft Diet toasted garlic bread with crust. During a review of the facility document titled, Cooks Spreadsheet, dated February 21, 2023, the document indicated for lunch on February 21, 2023, residents on a Mechanical Soft Diet should have received Soft-No hard crusts for the bread option. During a concurrent observation and interview…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-24 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 complete a Minimum Data Set (MDS) (a computerized clinical assessment) Significant Change Assessment (SCA) within 14 days for two of three sampled residents (Residents 31 and 27) who were reviewed for hospice (a program providing services for the care of terminally ill residents and their family) services as evidenced by: 1. The facility did not complete a MDS SCA for Resident 31 within 14 days of admission to hospice services. 2. The facility did not complete a MDS SCA for Resident 27 within 14 days of admission to hospice services. This failure had the potential to delay identification and implementation of necessary interventions to address the resident's care and support needs. Findings: 1. During a review of Resident 31's medical record, the admission Record (clinical records with demographic information) indicated the resident was admitted to the facility on [DATE]. The record further indicated the resident was admitted to hospice services on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-24 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately reflect the resident's status in the Minimum Data Set (MDS - Computerized resident assessment completed by a licensed nurse) Assessments when Section H: Bowel and Bladder was inaccurately coded for one sampled resident (Resident 59). This failure to correctly notify the oversight agency (Centers for Medicare and Medicaid Services - CMS) who provides funding for residents, has the potential for monies to continue to be paid to the facility for services not rendered to the resident. Findings: During a review of Resident 59's clinical record, the admission Record (contains admission and demographic information) indicated the resident was admitted on [DATE], with diagnoses which included infection of the skin, neuromuscular dysfunction of the bladder (lack of bladder control due to nerve problems), and paraplegia (paralysis of lower limbs). During a concurrent observation and interview on February 23, 2023, at 3:12 PM, Resident 59…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-24 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly assess and address pain levels, by not following physician's orders for pain medication, for one sampled resident (Resident 4). This failure had the potential to cause the resident to experience avoidable discomfort and pain. Findings: During a review of Resident 4's clinical record, the admission Record (contains admission and demographic information) indicated the resident was admitted on [DATE], with diagnoses which included cerebral infarction (lack of blood supply to the brain), heart failure (long term weakness of the heart muscle), and dementia (impaired ability to remember, think, or make decisions). Further review of the clinical record indicated there was a current physician's order for Norco (narcotic pain medication) Oral Tablet 10-325 mg (mg-milligrams - unit of measurement) Give 1 tablet by mouth every 6 hours as needed for Pain Management Moderate-Severe Pain 7-10 (pain rated on a scale from one [no pain] through…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-24 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 medications were administered as ordered for two (2) of six (6) residents (Resident 48 and Resident 62) observed during medication passes as follows: 1. For Resident 48 the manufacturer's specifications were not followed when Pantoprazole Sodium Delayed Release was crushed. 2. For resident 62 the physician's order for the Cranberry Supplement was not followed. This resulted in a medication error rate of 6.06 % in the 33 opportunities observed and had the potential to reduce the efficacy of the medications and to cause stomach irritation for Residents 48 and gave the wrong dose for Resident 62. Findings: 1. During a review of Resident 48's medical record, the admission Record (contains medical and demographic information), indicated Resident 48 was admitted on [DATE], with diagnoses which included unspecified encephalopathy (brain disease that alters brain function or structure), cerebral infarction (disrupted blood flow to the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-24 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 follow manufacturer's specifications for Pantoprazole Sodium Delayed Release tablet ordered for Resident 48. This failure had the potential for Resident 48 not to receive the maximum effect of the medication. Findings: During a review of Resident 48's medical record, the admission Record (contains medical and demographic information), indicated Resident 48 was admitted on [DATE], with diagnoses which included unspecified encephalopathy (brain disease that alters brain function or structure), cerebral infarction (disrupted blood flow to the brain due to unspecified occlusion of right middle cerebral artery) and gastro esophageal reflux disease (GERD-acid reflux) without esophagitis (inflammation of the esophagus- muscular tube through which food passes from the throat to the stomach). During a concurrent observation and interview on February 23, 2023, at 7:00 AM, with Licensed Vocational Nurse (LVN 3) outside Resident 48's room, LVN 3 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2026-01-08 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 46 resident's rooms (rooms [ROOM NUMBERS]) had the required 80 square feet (Sq Ft - unit of measurement) of space for each resident.This failure had the potential to negatively impact resident comfort, dignity, and safety by limiting adequate space for movement, equipment placement and staff assistance of four residents (Resident 1, 27, 35, and 57) who reside in the two rooms.Findings:During an interview on January 5, 2026, at 8:28 AM with the Director of nursing (DON) and the Administrator (Admin) the admin stated, the facility had two rooms (rooms [ROOM NUMBERS]) that were smaller than the required 80 Sq feet. The Admin stated they did not have any type of waiver variance for the room size.During an observation on January 5, 2025, at 9:32 AM, in room [ROOM NUMBER], no residents were currently in the room. The room was free of clutter, no concerns with the beds, bedside table, and the room was wheelchair accessible.During 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2023-02-24 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 46 resident rooms (rooms [ROOM NUMBERS]) had the required 80 square feet (Sq Ft - unit of measurement) of space for each resident. This failure had the potential to limit freedom of movement and affect the health and safety of four residents (Residents 71, 68, 57, and 229) who reside in the two rooms. Findings: During concurrent observation and interviews with the residents in room [ROOM NUMBER], on February 21, 2023, at 9:30 AM the following were observed: a. Bed A was occupied by Resident 71, who was observed resting comfortably in bed. Resident 71 stated she occasionally gets up into the wheelchair with staff assistance. Her wheelchair was folded up and stored in the room, out of the way of foot traffic, but easily accessible. b. Bed B was occupied by Resident 68, who was observed sitting in bed. Resident 68 stated she occasionally gets up into the wheelchair with staff assistance. Her wheelchair was folded up and stored…

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

    Environmental Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$31,899 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $22,932 — penalty dated 2024-10-18
  • $8,967 — penalty dated 2023-09-13
  • Medicare payment denial — starting 2024-11-15 for 11 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ROCKWELL HEALTHCARE — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 54.0≈ chain avg
Health inspection 4 of 54.0≈ chain avg
Staffing 3 of 52.8+0.2 vs chain
Quality measures 2 of 53.0-1.0 vs chain
The other 4 homes this chain runs (chain average 4.0★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
ROCKWELL HEALTHCARE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 07/01/2021
HERNANDEZ, GRACIELAIndividualW-2 MANAGING EMPLOYEEsince 03/24/2023
POWELL, SAWYERIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2021
POWELL, EVANGELINEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2021

CMS files one row per role, so the 7 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$14.1M
Net patient revenuemost recent cost report
+14.3%
Operating marginrevenue minus expenses
$687K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 60%Medicare 32%Other / private 9%

This home reported $687K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$425per resident / day
operating cost
$12,908per month
≈ monthly operating cost
$496per day
avg. revenue, all payers

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

What families pay in CA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 056365. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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