San Rafael Health and Rehabilitation

Location & what’s nearby

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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

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.

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.

44.4% 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 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 18.2% 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 22 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 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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.

Staffing

How full it usually is: this home is certified for 51 beds and averages 36.6 residents a day — about 72% occupied, or roughly 14 beds typically open. It usually has some room. 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 1.40 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.29 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 3.14 hrs/resident/day on weekends vs 4.15 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 1.61 to 0.87 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

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

27 citations, most serious first. The 16 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · J2024-11-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility document and policy review, the facility failed to protect Resident #38's right to be free from verbal and physical abuse perpetrated by Registered Nurse (RN) #6. This deficient practice affected 1 (Resident #38) of 4 sampled residents reviewed for abuse. Specifically, on 11/24/2023, RN #6 ; however, the CNA. On 11/26/2023, RN #6 yelled in Resident #38's face, shook the resident, and insisted the resident allow staff to transfer the resident back to bed. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation, F600, at a scope and severity of J. The IJ began during the nightshift on 11/24/2023 when RN #6 aggressively transferred Resident #38 from the recliner to the bed without consent from the resident. The certified nurse aides (CNAs) who witnessed 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-11-15 · 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

  Based on interview, record review, and facility document and policy review, the facility failed to ensure staff immediately reported allegations of abuse for 3 (Residents #38, #35 and #3) of 4 residents reviewed for abuse. Specifically, on 11/24/2024, certified nurse aides (CNAs) witnessed an incident involving Registered Nurse (RN) #6 and Resident #38 in which RN #6 aggressively transferred Resident #38 against their will; however, the CNAs who witnessed the transfer did not immediately report that they considered what they witnessed to be abusive, which allowed RN #6 to continue working with access to the resident. Subsequently, the CNAs witnessed a second incident on 11/26/2023 in which RN #6 grabbed Resident #38 and shook the resident to convince the resident to allow staff to transfer them back to their bed for care. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix…

  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
• Immediate jeopardy · J2024-11-15 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, document review, and facility policy review, the facility failed to thoroughly investigate allegations of abuse for 2 (Resident #35 and Resident #38) of 3 residents reviewed for abuse. Specifically, on 11/26/2023, RN #6 yelled in Resident #38's face, shook the resident, and insisted the resident allow staff to transfer the resident back to bed. Staff who witnessed the abuse did not immediately report the incident to administration, which resulted in a delay in initiating an investigation and implementing protective measures to prevent further abuse. As a result, RN #6 continued working in the facility and was involved in another incident of abuse toward Resident #38 on 11/26/2023. The facility's investigation of the incidents did not include interviews with other residents to determine if they had witnessed abuse or may have also been abused by RN #6 and did not include skin assessments to determine if other residents had bruises or other injuries that may have been attributed to abuse. Additionally, on 03/20/2024, the facility…

  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
• Actual harm · Gcited before2024-11-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, facility document review, and facility policy review, the facility failed to put interventions in place to prevent future falls for 2 (Resident #35 and Resident #27) of 2 residents reviewed for falls. The failure resulted in Resident #35 sustaining falls on 11/04/2023 which resulted in a laceration to the resident's head, 12/19/2023, 02/23/2024 which resulted in a right clavicle fracture, 05/21/2024 which resulted in an abrasion to their left knee, 07/12/2024, 07/22/2024 which resulted in swelling to the face and an abrasion on the nose, 07/27/2024, and 08/06/2024 with no evidence the facility initiated interventions after the falls to prevent future falls. Additionally, the facility failed to complete wandering assessments, ensure a resident was safe from eloping from the facility, and failed to investigate to find the root cause of an elopement for 1 (Resident #190) of 3 residents reviewed for elopement; and failed to ensure they assessed for resident safety before leaving medications at a resident's bedside for 1 (Resident #4) of 1 resident…

  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 before2021-06-17 · 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 it was determined, for 2 of 19 sampled residents, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, two residents that had multiple falls were not provided interventions or adequate supervision to prevent falls from occurring. One resident had to be transported to the emergency room on two occasions after sustaining lacerations that required sutures. In addition, a resident was not provided adequate supervision during smoking. Resident identifiers: 6 and 10. Findings include: 1. Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but not limited to atrial fibrillation, fall on same level from slipping, tripping and stumbling without subsequent striking against object, strain of muscle, fascia and tendon of lower back, laceration without foreign…

  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 · G2021-06-17 · 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 the review it was determined, for 1 of 19 sample residents, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident that complained of pain was unable to get a change in pain relief from the facility Medical Director (MD) for a week. Resident identifier: 17. Findings include: Resident 17 was admitted to the facility on [DATE] with diagnoses which included but not limited to acute and chronic respiratory failure, senile degeneration of brain, post-traumatic stress disorder, morbid obesity due to excess calories, chronic kidney disease stage 4, lichen sclerosus et atrophicus, essential hypertension, mood disorder due to known physiological condition, persistent mood [affective] disorder, chronic respiratory failure, type 2 diabetes mellitus with diabetic…

  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 · F2024-11-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
  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, facility document review, and facility policy review, the facility failed to maintain a clean and sanitary kitchen. These failures had the potential to affect 39 of 39 residents who received meals from the dietary department. Findings included: A facility policy titled, Cleaning Schedules, updated 03/2014, revealed, The Dietary staff shall maintain the sanitation of the Dietary Department through compliance with written, comprehensive cleaning schedules developed for the community by the Dietary Manager. The policy revealed, 7. Under the days of the week or the weeks the Dietary Manager or designee can check off assignments completed or the employee can initial. A facility policy titled, Operation and Sanitation, revised 11/01/2011, revealed, Operating instructions are made available and cleaning procedures are developed for all Dietary Department equipment. Observations during the initial tour of the kitchen on 10/14/1024 beginning at 8:50 AM, revealed the appliances, including the commercial oven, convection oven, grill, and steamer, were dirty…

  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 · F2024-11-15 · tag F0943 — widespread
  Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, document review, and facility policy review, the facility failed to provide annual and periodic training in accordance with facility policy, to educate staff on activities that constitute abuse and procedures for reporting incidents of abuse for 2 (Certified Nurse Aide [CNA] #8 and Registered Nurse [RN] #6) of 4 staff reviewed. Findings included: A facility policy titled, Policy and Procedure for Prohibiting Abuse, dated 02/2017, indicated, 2. Training All employees will be trained through orientation and ongoing inservices on issues related to the prohibition of abuse including: - Appropriate behavioral interventions to deal with aggressive and/or catastrophic reactions of residents - How to report allegations without fear of reprisal - Signs of burnout, frustration and stress that may lead to abuse - What constitutes abuse, neglect and misappropriation of resident property. 3. Prevention of abuse This facility carefully screens potential employees. Initial orientation and periodic inservices at least twice a year regarding abuse prevention and reporting,…

  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 · E2024-11-15 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, facility document review, and facility policy review, the facility failed to consistently follow up on concerns presented by the Resident Council (RC) and provide a verbal or written response to the RC regarding any actions taken to address their concerns. There was incomplete or no follow-up documented for 5 (January, May, July, August, and September 2024) of 10 months of RC minutes reviewed. Findings included: A facility policy titled, Grievances/Complaints, Recording and Investigating, revised April 2017, indicated, All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). The policy also specified, 5. The grievance officer will record and maintain all grievances and complaints on the 'Resident Grievance Complaint Log.' The following information will be recorded and maintained in the log: a. The date the grievance/complaint was received; b. The name and room number of the resident filing the grievance/complaint (if available); c. The name and relationship of the person filing…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-11-15 · tag F0656 — failed to write and follow a full care plan — pattern
  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

  Based on observation, interview, record review, and facility policy review, the facility failed to develop individualized resident-centered care plans with measurable objectives for 4 (Residents #1, #3, #24, and #4) of 14 residents whose care plans were reviewed. Specifically, the facility failed to ensure care plans addressed oxygen use for Resident #1 and Resident #3, failed to ensure a care plan addressed an indwelling urinary catheter for Resident #24, and failed to ensure a care plan addressed respiratory care for a diagnosis of chronic obstructive pulmonary disease (COPD) and respiratory medications for Resident #4. Findings included: A facility policy titled, Care Plans, Comprehensive, Person-Centered, revised 03/2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy specified, 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-11-15 · tag F0658 — failed to meet professional standards of care — pattern
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and facility policy review, the facility failed to ensure physician's orders included all necessary components, including the specified dosages for 2 (Residents #13 and Resident #20) of 3 residents who were observed during the medication administration task. Findings included: A facility policy titled, Physician Medication Orders, revised in 04/2010, specified, 6. Orders for medications must include: a. Name and strength of the drug and c. Dosage and frequency of administration. A facility policy titled, Medication Orders, revised in 11/2014, specified, 1. Medication Orders- When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. 1. An admission Record indicated the facility admitted Resident #13 on 01/03/2024. According to the admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus, chronic kidney disease, hypertension, intervertebral disc degeneration, and osteoporosis. Resident #13's Order Summary Report, listing active orders as…

  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 · E2024-11-15 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to implement infection control and prevention policies. Specifically, the facility failed to ensure staff followed enhanced barrier precautions (EBP) when completing indwelling urinary catheter care for 1 (Resident #24) of 1 resident reviewed for indwelling urinary catheter care. Additionally, the facility failed to conduct annual tuberculosis (TB) risk screenings for 4 (Residents #1, #3, #4, and #27) of 5 residents whose immunization histories were reviewed. Findings included: 1. A facility policy titled, Enhanced Barrier Precautions Policy and Procedure, revised 03/27/2024, indicated, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms ([NAME]) [sic - MDROs] in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-11-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure an indwelling urinary catheter was secured to prevent potential pulling/trauma to the urethral meatus for 1 (Resident #24) of 1 sampled resident observed for indwelling urinary catheter care. Findings included: A facility policy titled, Catheter Care, Urinary, revised 08/2022, indicated under General Guidelines, to, 4. Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site. The State Operations Manual (SOM) Appendix PP - Guidance to Surveyors for Long Term Care Facilities guidance at tag F690 specified additional care practices related to catheterization included, Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter. An admission Record revealed the facility initially admitted Resident #24 on 06/01/2022 and readmitted the resident on 01/06/2023. According to the admission Record, the resident had a medical history that included…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-11-15 · 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

  Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure pharmacy recommendations were addressed for 1 (Resident #26) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Pharmacy Services Committee, revised 12/2009, indicated, Duties and responsibilities of the Pharmacy Services Committee include, but are not limited to: 12. Reviewing the reports of the Consultant/Supervising Pharmacist. An admission Record indicated the facility admitted Resident #26 on 04/03/2022. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia and paranoid personality disorder. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/14/2024, revealed Resident #26 had moderate impairment in cognitive skills for daily decision-making and had a short-term memory problem per a Staff Assessment of Mental Status (SAMS). The MDS revealed the resident received an antipsychotic, antianxiety, antidepressant, an opioid,…

  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 before2024-11-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
  Implement 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

  Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure an as-needed (PRN, pro re nata) psychotropic medication order specified the duration of use for 1 (Resident #26) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Psychotropic Medication Use, dated 07/2022, specified, 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. An admission Record indicated the facility admitted Resident #26 on 04/03/2022. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia and paranoid personality disorder. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/14/2024, revealed Resident #26 had moderate impairment in cognitive skills for daily decision-making and had a short-term memory problem…

  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 before2024-11-15 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility document review, and facility policy review, the facility failed to maintain accurate medical records for 1 (Resident #190) of 19 sampled residents. Findings included: A facility policy titled, Record of Admission, revised December 2006, revealed, A record of admissions will be maintained for each resident admitted to the facility. The policy revealed, 1. At the time of the resident's admission, a resident identification and summary record is completed. 2. A copy of this record must be placed on the resident's chart, and a copy must be provided to the medical records department. 3. Our identification and summary record includes, but is not limited to: a. the resident's full name and social security number; b. the date and time of this admission. An admission Record revealed the facility admitted Resident #190 on 08/04/2023. According to the admission Record, the resident had a medical history that included Alzheimer's disease, insomnia, dementia with agitation, and…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$29,347 in federal fines across 2 penalties.

• $25,929 — penalty dated 2024-11-15
• $3,418 — penalty dated 2024-02-06

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

Who owns this facility

CMS files one row per role, so the 15 rows in the source record cover these 6 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 $193K 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

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 UT