Home / California / North Hills
9655 Sepulveda Boulevard, North Hills, CA 91343 · Los Angeles County · (818) 892-8665
138 certified beds, about 127 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1977
CMS Care Compare ratings, data as of September 1, 2026 · CCN 056367 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on July 16, 2026, inspectors cited 13 health deficiencies (the California average is 15.6, the national average 9.2).
Of 104 health citations since September 2023, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $102,986 in the last three years; the largest was $102,986, and the latest is dated July 11, 2024.
Nurses and nurse aides worked 4.58 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 0.91 of those hours.
29.9% of nursing staff left within the year CMS measured (California average 36.7%).
CMS links it to Pursue Health, an affiliated group of 7 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 104 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to ensure that staff monitored and documented intake (food and fluid consumption) and output (urine and stool amounts) in accordance with professional standards of practice and per the facility's policy and procedure (P&P) for one of three sampled resident (Resident 1), who had a nephrostomy tube (N-tube - a tiny plastic tube put through the skin of your back directly into the kidney to drain urine out of the body into an external bag). This deficient practice had the potential to result in unrecognized nephrostomy tube obstructions, leakages, or improper urine drainage and negatively affect the resident's health status.
Inspectors wroteBased on interview and record review, the facility failed to notify a physician regarding a resident's refusals for changing the dressing on their nephrostomy tube (N-tube - a tiny plastic tube put through the skin of your back directly into the kidney to drain urine out of the body into an external bag) stoma (a small, surgically made opening in the skin of the back that leads directly into the kidney) for one of three sampled residents (Resident 1). This deficient practice placed the resident at risk for kidney and/or wound infection, increased risk of hospitalization related complications, and a decline in the resident's overall health status.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) addressing a resident's refusal for changing the dressing on their nephrostomy tube (N-tube - a tiny plastic tube put through the skin of your back directly into the kidney to drain urine out of the body into an external bag) stoma (a small, surgically made opening in the skin of the back that leads directly into the kidney) for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the delivery of care and services to a resident.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person centered care plan (a document outlining individualized approaches to meet a resident's specific needs) for 1 out of 26 sampled residents (Resident 118) by failing to: 1. Develop an accurate, person centered care plan for Resident 118 who has diagnosis of epileptic seizure (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, sensations, awareness, or consciousness) to monitor and document presence or absence of seizure activity. 2. Implement the care plan interventions for monitoring, documenting, and reporting hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) signs and symptoms as indicated in the care plan titled, At risk for hypoglycemia/hyperglycemia related to diagnosis of DM.3. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 20) was assessed to ensure the resident's ability to self-administer an over-the-counter ointment medication and was able to store it in a safe and secure area. This failure had the potential to result in the wrong administration of the ointment medication and/or the risk of other residents taking the ointment medication for their own use. 2. Ensure one of two crash (a crash cart is an emergency medical cart that contains critical life saving equipment and supplies, including medications, airway devices, and sharps such as needles carts (Cash Cart 1) was properly secured. This failure had the potential to result in accident hazards and delayed emergency care for residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Resident 112, Resident 130, Resident 57, and Resident 157) did not have a loop or kink (unwanted twist or bend) in their urinary catheter tubing (a hollow tube inserted into the bladder to drain or collect urine). This failure had the potential for urine backflow into the bladder, increasing the risk of the residents of a urinary tract infection (UTI-an infection in the bladder/urinary tract).
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe storage and labeling of medication when: 1. Expired vitamin D supplements (concentrated sources of the essential nutrient vitamin D, which supports bone and immune health) and improperly labeled nicotine lozenges (a medication used to help people quit smoking) were stored and available for use in one of two inspected medication rooms (Station 3 medication room). 2. An internal use medication (a medication intended to be taken by mouth, injection, or inhaled) indicated for under the tongue administration was stored with an external use medication (a medication intended to be applied to the eyes, ears, nose, or skin) in one of four medication carts (Nurse Station 1 Medication Cart 1). These failures placed residents at risk of receiving incorrect, contaminated, or expired medications.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and distribution practices, by failing to: 1. Ensure potentially hazardous foods prepared and stored beyond 24 hours were labeled with a use-by date. 2. Ensure potentially hazardous foods prepared and stored beyond seven (7) days were discarded. 3. Ensure potentially hazardous foods kept in the walk-in refrigerator beyond manufacturer expiration dates were discarded. 4. Ensure potentially hazardous foods kept in the resident refrigerator beyond manufacturer expiration dates were discarded. These failures had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 86 of 130 residents who received food from the facility kitchen and the resident refrigerator.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for one of 26 sampled resident (Resident 148). This failure had the potential to result in Resident 148 not being able to call for facility staff assistance and delay in the provision of necessary care and services which could negatively affect the residents' comfort and well-being.
Inspectors wroteBased on interview and record review, the facility failed to ensure one of 26 sampled residents' (Resident 48's) diagnoses were reflected in the resident's list of diagnoses in the Minimum Data Set (MDS - a resident assessment tool). The MDS did not include the diagnoses of depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), psychotic disorder (severe mental illnesses characterized by a disconnection from reality, primarily involving hallucinations [seeing or hearing things not there] and delusions [false, fixed beliefs]), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). [...]
Inspectors wroteBased on interview, and record review, the facility failed to review and revise the comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) for two of 26 (Resident 8 and 112) sampled residents. This failure practice had the potential for Residents 8 and 112 not to receive the necessary care and services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to set a resident's low air loss mattress (LALM - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) in accordance with the physician's order for one out of one sampled resident (Resident 122) investigated for pressure ulcer/injury (also known as pressure sores and decubitus ulcers, localized damage to skin and/or underlying tissue caused by prolonged pressure or friction, often over bony areas a skin and soft tissue injury that occurs when skin is under pressure). This failure placed the resident at risk for discomfort and development of new and or worsening of pressure ulcers.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care supplies for two of two sampled residents (Resident 9 and Resident 67) reviewed under the respiratory care area, were changed in accordance with professional standards of practice and facility's policy and procedure. This failure had the potential to place the residents at increased risk of developing respiratory tract infections and distress.
Inspectors wroteBased on observation, interview, and record review, the facility failed to document the administration of a dose of ciprofloxacin (an antibiotic medication used to treat infections) in the medication reconciliation log (a sheet used to compare medical orders with the medication given to a resident to prevent errors, omissions, duplication, and maintain medication count) for one of three sampled medication carts (Nurse Station 1 Medication Cart 1). This failure resulted in a medication count discrepancy of ciprofloxacin and had the potential to result in a double dosage administration to the resident which can lead to adverse reactions (undesired harmful effect resulting from a medication or other intervention).
Inspectors wroteBased on interview and record review, the facility failed to ensure that all of a resident's active diagnoses were reflected in the admission Record under the Diagnosis Information section for one of one sampled resident (Resident 48). This failure resulted in Resident 48's admission Record containing incomplete information and had the potential to create confusion in the delivery of care and services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices and food handling practices by failing to ensure leftover milk is removed from the resident`s bedside after two hours for one of one resident (Resident 40). This deficient practice had the potential to place the resident at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PIs - injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]), for one of four sampled residents (Resident 2) by failing to set the LALM to the correct mode while the resident was lying in bed, and by placing multiple layers of linens on top of the LALM. [...]
Inspectors wroteBased on interview and record review, the facility failed to notify a resident's family/representative regarding a resident missing their doctor's appointment for one of five sampled residents (Resident 4). This deficient practice had the potential for Resident 4's family not to be involved in Resident 4's plan of care.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for two of four sampled residents (Resident 1 and Resident 2) when the facility failed to trim and clean the residents' fingernails. This deficient practice resulted in Resident 1 and Resident 2 having long fingernails, placing the residents at increased risk for infection, skin breakdown and injury, and cross contamination; and had the potential to negatively affect the residents' comfort, self-esteem, and sense of dignity.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure no more than two layers of linen were placed on top of the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI - injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) for one of four sampled residents (Resident 1). This deficient practice had the potential to increase the resident's risk of skin breakdown.
Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive, person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one (1) of three (3) sampled residents (Resident 1), that addressed Resident 1's use of continuous oxygen. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation of the administration of medications for one (1) of three (3) sampled residents (Resident 1), by failing to document the administration of Resident 1's medication on the Medication Administration Record (MAR - a report detailing the medications administered to a resident by the licensed nurse in the facility). This deficient practice had the potential to result in medication errors and/or drug diversion (illegal distribution or abuse of prescription drug). [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure the resident assessment accurately reflected the residents' status for one (1) out of three (3) sampled residents (Resident 1). This deficient practice had the potential to lead to a delay or lack of delivery of care and services for Resident 1. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1) that addressed:1. Resident 1's hearing difficulty; 2. Resident 1's wounds; and 3. Resident 1's indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to:1. Ensure Restorative Nursing Assistant 1 [RNA 1]) had not worn long artificial fingernails according to facility policy while providing direct resident care for one of five sampled residents (Resident 1).2. Ensure one of 12 sampled staff (Janitor 1) wore gloves while collecting and discarding trash bags and performed hand hygiene (cleaning hands by either washing with soap and water, or by using a hand sanitizing gel) after handling and discarding trash bags.3. [...]
Inspectors wroteBased on interview and record review the facility failed to ensure the discharge planning process for one of three sampled residents (Resident 1) included an interdisciplinary team (IDT-a group of professionals including physicians, nursing, social services, therapy, and activities department who work together to achieve a shared goal for the resident) meeting prior to Resident 1 being transferred to a board and care facility (small, residential homes that provides personal care and support services for a limited number of residents) to ensure discharge readiness and/or appropriateness of the receiving board and care facility. This deficient practice placed Resident 1 at risk for unmet care needs, potential medication mismanagement, and overall functional decline in health status.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for three of 27 sampled residents (Resident 75, 94, and 82) by failing to: 1. Develop a care plan addressing Resident 75's use of bed siderails. ? 2. Develop a care plan addressing Resident 94's preferred language for communication. 3. Develop a care plan addressing Resident 82's multiple joint contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and limited range of motion (ROM, full movement potential of a joint). These deficient practices had the potential to result in failure to deliver the necessary care and services.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 10 sampled residents (Resident 82) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) by failing to: 1. Provide sufficient physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) and occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) services to safely assess and monitor Resident 82's use of a new left elbow splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint), new left hand splint, new right knee splint, new left knee splint, and new left ankle splint on 9/20/2024. 2. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. Ensure that a licensed nurse did not leave 11 medications at a resident`s bedside who was assessed as not safe to self-administer oral medications for one of two residents (Resident 11). This deficient practice had the potential for the resident to choke on the medications upon oral ingestion while unsupervised. b. Provide bed rail padding for a resident with a history of epileptic seizures (a sudden surge of abnormal electrical activity in the brain, leading to a range of symptoms like muscle spasms, loss of consciousness) as ordered by the physician for one of one resident (Resident 54). This deficient practice placed Resident 54 at an increased risk for injuries. c. [...]
Inspectors wroteBased on interview and record review the facility failed to: 1. Account for two (2) doses of Controlled Medication (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 13 and 110 in one (1) of four (4) inspected medication carts (Medication Cart 1 Station 3.) 2. Identify and report CM discrepancy for June 2025 in one (1) of four (4) inspected medication carts (Medication Cart 2 Subacute.) 3. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label one Timolol (a brand name medication used to treat glaucoma [a condition of increased pressure in the eyeball]) eye drop bottle for Resident 89, with an open date in accordance with facility requirements and manufacturer's requirements in one (1) of four (4) inspected medication carts (Medication Cart 2 Station 3.) 2. Remove and discard from use one (1) open, expired insulin (medication used to regulate blood sugar levels) Humulin N (an intermediate acting insulin) Kwikpen (an injection device containing insulin) stored at room temperature for Resident 101, in accordance with manufacturer's requirements and facility policy and procedures in one (1) of four (4) inspected medication carts (Medication Cart 1 Subacute.) 3. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when: 1. [NAME] 1 did not follow the recipe for garlic buttered rice 2. [NAME] 1 did not follow portion sizes for small and large portions by serving three (3) ounces (oz, a unit of measurement) instead of two (2) oz and four (4) oz respectively. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature, flavor and appearance when: 1. The temperature of the foods were as follows: a. Pound cake with strawberries and whip cream was at 56.5 degrees Fahrenheit (°F, a scale of temperature) b. Zucchini 115°F, c. Puree (a texture modified diet that consists of smooth, moist foods that are easy to swallow, food with soft pudding like consistency) pound cake with strawberries and whip cream was at 60°F 2. Zucchini was soggy and overcooked. 3. Gravy drippings were on the side of the plate. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when the pureed (a texture-modified diet composed of foods that have been ground, pressed, or strained to a soft, smooth consistency, similar to pudding) roast pork was runny and did not hold its shape on the plate and pureed bread lacked a smooth pudding like consistency, containing visible bread particles. These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 10 of 10 residents on pureed diet, resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen, as evidenced by the following: 1. There was no thermometer inside the reach-in freezer (refers to a standard freezer that allows for easy access to the frozen items stored inside) for temperature monitoring. 2. Kitchen equipment and kitchen areas were observed to be unclean and not sanitized. a. Walk-in freezer (a large, refrigerated room designed for storing frozen food items) curtains were observed to have stickers, sticker residues and food spills. b. Walk-in refrigerator (refers to a large, walk-in storage space, used to store perishable food items) vent had dust build-up. c. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly (to dispose of waste materials [refuse] in a way that complies with regulations and best practices, minimizing environmental and health risks) when there were soiled gloves, empty plastic cups, liquid spills and other trash on the floor and surrounding areas of the dumpster bin (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts). This deficient practice had potential to attract birds, flies, insects, and pests (any unwanted organism that can contaminate or interfere with food safety and hygiene), and possibly spread infection to 78 of 120 facility residents.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain accurate and complete resident medical records for two of 10 sampled residents (Resident 82 and 48) when nursing staff failed to: 1. Document when nursing staff did not put on a left hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) on Resident 82 three to four hours a day, seven days a week as ordered by a physician. These deficient practices resulted in inaccurate medical documentation and had the potential for worsening of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the left wrist and hand in Resident 82. 2. [...]
Inspectors wrote(b.) During a review of Resident 16's admission Record, the admission Record indicated the facility originally admitted the resident on 5/12/2009 and readmitted the resident on 7/7/2015 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 4/1/2025, the MDS indicated the resident had severely impaired cognition (thought processes) and was dependent for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 77's admission Record, the admission Record indicated the facility originally admitted the resident on 4/18/2023 and readmitted the resident on 1/16/2024 with diagnoses including dysphagia (difficulty swallowing). [...]
Inspectors wroteBased on interview and record review, the facility failed to provide care in a manner that maintained a resident's dignity and respect for one of two sampled residents, reviewed under the care area of dignity by failing to ensure Treatment Nurse 1 (TN1) knock or request permission before entering Resident 82's room. This deficient practice violated the resident`s rights to be treated with respect and dignity and had the potential to affect the residents` sense of self-worth and self-esteem.
Inspectors wroteBased on interview and record review, the facility failed to provide the resident and the resident's representative information regarding formulating an advance directive (AD-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor for one of six sampled residents investigated during review of advance directive care area (Resident 82). This deficient practice had the potential for Resident 82 and their representative to not be informed of their right to formulate an advance directive and not honor the resident's wishes regarding end-of-life care.
Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the resident's physician for one of 10 sampled residents (Resident 82) when licensed nursing staff failed to put on a left hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for three to four hours a day, seven days a week as ordered by a physician. This deficient practice had the potential to cause a decline in range of motion (ROM, full movement potential of a joint) and worsening of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in Resident 82.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident receiving risperidone (used to treat schizophrenia [mental disorder in which people interpret reality abnormally]) was monitored for a specific paranoid (intense anxious or fearful feelings and thoughts) behavior exhibited for one of three residents (Resident 75). This deficient practice had the potential to result in inaccurate evaluation of the efficacy of risperidone and placed the resident at risk of experiencing medication adverse effect (undesired harmful effect resulting from a medication or other intervention) such as hypotension (low blood pressure) which could lead to fall and injury.
Inspectors wroteBased on interview and record review, the facility failed to conduct a quarterly review of a resident's comprehensive care plans (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of one resident (Resident 75). This deficient practice had the potential to result in failure to deliver the necessary care and services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: A. Ensure a resident's low air loss mattress (LALM - designed to distribute a resident's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight per manufacturer's guidelines for one (Resident 82) out of five sampled residents investigated for pressure ulcer/injury (PI/PU, injuries to the skin and underlying tissue resulting from prolonged pressure). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers. B. [...]
Inspectors wroteBased on interview and record review, the facility failed to assess and document the location and characteristic of a resident's pain prior to pain medication administration for one of one sampled resident (Resident 110) investigated under the pain care area. This deficient practice had the potential for inadequate management of Resident 110's pain resulting in decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse 8 (LVN 8) possessed the necessary knowledge and skills to properly assess and evaluate one of one sampled resident (Resident 630's) food allergy (when your body's immune system mistakenly identifies a food as harmful and triggers a reaction). This deficient practice placed Resident 630 at risk of being exposed to an allergen (substance that can cause an allergic reaction), which could have led to a serious allergic reaction (a condition that causes illness when someone eats certain foods or touches or breathes in certain substances).
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident obtained needed dental services when one of two residents (Resident 13) did not have their dental services coordinated to provide dental extractions as recommended by the dentist. This deficient practice had the potential for Resident 13 to experience pain, infection, chewing problems, and weight loss.
Inspectors wroteBased on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 630's) food allergy (when your body's immune system mistakenly identifies a food as harmful and triggers a reaction) was honored when the food allergy was not entered in Resident 630's medical records in a timely manner, and staff did not accurately enter the food allergy into the meal order system. The diet ticket (a slip of paper or digital record that specifies which meal a resident is supposed to have and when and used by the kitchen staff to ensure each resident receives the correct food at the correct time) indicated an allergy to bell peppers instead of all peppers. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain one of six rehabilitation therapy (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) equipment for resident use. This failure had the potential for injury and spreading of infections to residents using the therapy equipment.
Inspectors wroteBased on observation, interview and record review the facility failed to provide one of one resident (Resident 103), reviewed under the privacy care area, full visual privacy (a resident has a means of completely withdrawing from public view, without staff assistance, while occupying their bed [for example, curtain, moveable screens]) by not ensuring that ceiling suspended curtains extended fully around the resident's bed. This deficient practice prevented Resident 103 from having full privacy from public view.
Inspectors wroteBased on interview and record review, the facility failed to transmit a resident's Discharge Minimum Data Set (MDS - a resident assessment tool) timely for one of one sampled resident (Resident 115). This deficient practice had the potential to delay care and services for the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 27 out of 55 resident rooms (Rm 103, 105, 106, 107, 108, 109, 110, 111, 112, 201, 210, 211, 213, 215, 216, 217, 301, 302, 303, 309, 311, 312, 313, 315, 321, 323, 325) met the square footage requirement of 80 square feet (sq ft- unit of measure) per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed nurse documented the administration of levetiracetam (a medication used to treat seizures [a sudden, temporary disruption in brain electrical activity that can cause involuntary changes in body movement, behavior, sensation, or awareness]) on the Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) after administering the medication to one of one sampled resident (Resident 1). This deficient practice had the potential to result in medication errors and had the potential to result in confusion on the delivery of care and services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide materials to facilitate communication for a resident with speech disabilities for one of four sampled residents (Resident 1). This deficient practice had the potential to prevent the resident from communicating with the staff and had the potential to delay receiving care/treatment the resident needed.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS - a resident assessment tool) section regarding the total number of venous ulcers (wounds caused by impaired blood flow in the [veins] blood vessels that return blood to the heart) and arterial ulcers (wounds caused by insufficient blood supply in the [arteries] blood vessels that carry blood away from the heart to the body) was accurate for one of four sampled residents (Resident 1). This deficient practice had the potential to result in a delay in necessary care and treatment.
Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of four sampled residents (Resident 1), to address Resident 1's noncompliance with his physician ordered diet. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices to prevent the spread of Coronavirus Disease 2019 (COVID 19 - a highly contagious respiratory illness in humans capable of producing severe symptoms) by failing to ensure two of two sampled staff (Respiratory Therapist 1 [RT 1] and Licensed Vocational Nurse 1 [LVN 1]) wore an N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) while in the facility during a COVID 19 outbreak (a sudden increase in the number of COVID 19 positive cases). This deficient practice had the potential to result in an increase of COVID 19 positive cases and had the potential to result in the spread of infection placing residents, staff, and visitors at risk to be infected with COVID 19.
Inspectors wroteBased on interview and record review, the facility failed to implement the facility's bed-hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) policy by failing to provide residents and/or the residents' responsible party with a notice of bed-hold upon transferring the residents to the general acute care hospital (GACH) for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This deficient practice had the potential to deprive the residents and/or the residents' responsible party, the right to be informed of their rights regarding bed-holds.
Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three of three sampled residents (Resident 1, Resident 2, and Resident 3) by failing to document residents ' name, date of birth , and admission date as indicated on the facility ' s Bedhold Information Consent form. This deficient practice has the potential to result in residents ' medical records not being identifiable due to the incomplete information on Resident 1, Resident 2, and Resident 3 ' s Bedhold Information Consent form.
Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by Resident 2 for one of two sampled residents (Resident 1). On 2/2/2025, Certified Nursing Assistant 1 (CNA 1) witnessed Resident 2 punch Resident 1 with a closed fist, three times on the left side of Resident 1's chest. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of two sampled residents (Resident 1), who had a new onset of pain on 2/2/2025. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.
Inspectors wroteBased on interview and record review, the facility failed to monitor a resident for 72 hours after a Change of Condition (COC- sudden deviation from a resident ' s baseline in physical, cognitive [involving the processes of thinking and reasoning], behavioral, or functional domains) for one of two sampled residents (Resident 1) as indicated in the facility policy. This deficient practice had the potential to place the resident at risk of not receiving appropriate care due to the lack of monitoring and had the potential to negatively affect the resident ' s psychosocial (the mental, emotional, social, and spiritual effects of a disease) well-being and delay in attaining the resident ' s highest practicable mental and psychosocial well-being.
Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy on pain assessments as evidenced by failing to ensure a pain assessment was completed quarterly (every three months) and for new onset of pain on 2/2/2025 for one of two sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1 not maintaining Resident 1's highest possible level of comfort.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's attending physician documented a resident's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) annually for one of two sampled residents (Resident 2). This deficient practice had the potential for inconsistent care coordination due to incomplete records for Resident 2.
Inspectors wroteBased on interview and record review the facility failed to account for 16 tablets of hydromorphone hydrocholoride (Dilaudid- controlled medication [medications with a high potential for abuse] used to treat severe levels of pain) for one of three sampled residents (Resident 1). This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of the controlled medication and had the potential for Resident 1 to have increased discomfort, increased pain levels and decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two of four sampled residents by failing to: 1. Document Resident 1 and Resident 3 ' s blood sugar readings and or insulin administered in the Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). 2. Document Resident 1's blood sugar (BS) reading accurately in the resident's blood sugar summary records. This deficient practice resulted in incomplete resident medical care information for Resident 1 and Resident 3 and placed the residents at risk for not receiving the appropriate care and treatment related to management of diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident ' s call light (a devices used by a resident to signal his/her need for assistance from staff) was answered promptly for one of four sampled residents (Resident 3). This deficient practice had the potential to delay the provision of services and residents' needs not being met.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for one of three sampled residents (Resident 1), who was identified to have an amputation (the action of surgically cutting off a limb). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.
Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy on skin assessment as evidenced by failing to ensure reassessments were done timely using the Braden Scale (a standardized tool used to assess a resident's risk for developing pressure ulcer [injury to skin and underlying tissue resulting from prolonged pressure on the skin]) for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 2 and Resident 3.
Inspectors wroteBased on interview and record review, the facility failed to monitor a resident for 72 hours after a Change of Condition (COC- sudden deviation from a resident's baseline in physical, cognitive [involving the processes of thinking and reasoning], behavioral, or functional domains) was completed for an abuse allegation for one of two sampled residents (Resident 1). This deficient practice had the potential to place the resident at risk of not receiving appropriate care due to the lack of monitoring and had the potential to negatively affect the resident's psychosocial (the mental, emotional, social, and spiritual effects of a disease) well-being and delay in attaining the resident's highest practicable mental and psychosocial well-being.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care consistent with the professional standards of practice to help prevent pressure ulcer (also known as pressure injury, an injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of seven sampled residents (Resident 3) by failing to ensure weekly wound monitoring assessments for pressure ulcer were done on a weekly basis. This deficient practice had the potential for development and worsening of pressure ulcer to Resident 3.
Inspectors wroteBased on interview and record review the facility failed to follow its policy and procedure (P&P) titled Fall Management Program for one of three sampled residents (Resident 1), when on 7/22/2024, Certified Nurse Assistant (CNA 1) did not utilize a geriatric-shower chair (Geri-chair- a large, padded wheeled chair that can be used in the shower that is designed to assist residents with limited mobility) while providing shower assistance to Resident 1. This deficient practice resulted in Resident 1 having an assisted fall (when a resident falls and a staff member is present to help the resident to the ground or break the fall) while in the shower, and placed Resident 1 at risk for injury and decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring for changes in urine characteristics and signs and symptoms of a urinary tract infection (UTI - an infection in any part of the urinary system) for a resident with an indwelling catheter (a flexible tube that drains urine from the bladder) was done for one of five sampled residents (Resident 1). This deficient practice had the potential for a delay in care and services and potential for Resident 1 to develop an unrecognized UTI.
Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 79), who was at risk for pain and distress (state of extreme sorrow, suffering, or pain) related to chronic pain syndrome (persistent pain that lasts weeks to years) received care and services in accordance with professional standards of practice by failing to ensure Resident 79's unrelieved pain was managed. 2. Ensure nonpharmacological interventions (science-based, non-invasive healthcare interventions that are not primarily based on medication) were provided by the licensed nurses prior to administering as needed (prn) opioid medication (powerful pain-reducing medications) for three (Residents 278, 38, and 41) out of 34 sampled residents. [...]
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for four of 34 sampled residents (Resident 115, 67, 103, and 427) by failing to: 1. Develop a care plan addressing Resident 115's visual impairment. 2. Develop a care plan addressing Resident 67, Resident 103, and Resident 427's use of a low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure ulcers [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]).
Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure ulcers [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) or alternating pressure mattress (APP - uses air to redistribute pressure across a sleeping surface) was set correctly for two of 34 sampled residents (Resident 35 and 117). 2. Ensure there was a physician's order for use of a LAL mattress for two of 34 sampled residents (Resident 427 and 40) These deficient practices had the potential to increase the resident's risk of skin breakdown or delay the treatment of pressure ulcers.
Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation of the administration of a medication order for Netarsudil Dimesylate Ophthalmic Solution (generic name for Rhopressa Ophthalmic Solution , an eye drop medication used to lower eye pressure in people with glaucoma [a condition in which increased pressure in the eye can lead to gradual loss of vision] or ocular hypertension [a condition where the pressure inside the eye is higher than normal]) by transcribing twice (generic name and brand name) in the electronic Medication Administration Record (MAR- the report that serves as a legal record of the medications administered to a resident of a facility by a health care professional) for one of one resident (Resident 115) reviewed under Quality of Care. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a facility staff knocked and asked permission prior to going inside a resident's room for one of two rooms (Room A) observed during a facility tour. This deficient practice violated the resident's rights to be treated with respect and dignity which had the potential to affect the resident's sense of self-worth and self-esteem.
Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) was obtained from a resident and/or the resident's responsible party (person, usually a family member who makes medical decisions for a resident) for one of two sampled residents (Resident 114) regarding the use of an antipsychotic medication (a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]). This deficient practice had the potential for the resident and/or the resident's responsible party to not be informed on medication therapy decisions that may affect a resident's health conditions.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for one of one sampled resident (Resident 62). This deficient practice had the potential to cause a delay in resident care and for the resident's needs to remain unmet.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Restorative Nursing Assistant 1 (RNA 1) provided privacy to a resident while the resident received exercises for one of 34 sampled residents (Resident 35). This deficient practice violated the resident's right to privacy.
Inspectors wroteBased on interview and record review, the facility failed to permit one of one sampled resident (Resident 71) to return to the facility after hospitalization. Resident 71 was permitted to the facility on 7/10/2024. This deficient practice subjected Resident 71 to an unnecessary prolonged hospitalization.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident, who was assessed as unsafe to self-administer medications, was not left unattended with a bottle of antacid (a medication that relieves heartburn in the stomach by reducing the amount of acid in the stomach) at the bedside for another resident to take for one of one sampled resident (Resident 44). This deficient practice had the potential for other residents to enter the room and take the medication.
Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure that Licensed Vocational Nurse 4 (LVN 4) checked the placement of the gastrostomy tube (G-tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) before administering medications for one of two sampled residents (Resident 81) observed during the medication pass (the process through which medication is administered to a resident) observation. This deficient practice placed Resident 81 at risk for injury if medications were administered into a displaced (outside the stomach) G-tube. 2. Ensure the G-tube feeding bottle was labeled for one of 34 residents (Resident 80) who were prescribed with G-tube feeding. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's as needed (PRN) lorazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) had a specific duration for one of 34 sampled residents (Resident 35). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain accurate medical records for one of 34 sampled resident (Resident 478) by failing to ensure Licensed Vocational Nurse 2 (LVN 2) document the correct location of Resident 478's body part where the blood pressure (BP- the pressure of blood on the walls of your arteries as your heart pumps blood around your body) reading was obtained. This deficient practice had the potential to result in confusion regarding Resident 478's condition and what care and services were provided to Resident 478.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 8 (LVN 8) donned (to put on) a gown prior to administering medications via gastrostomy tube (G-tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) for one of 34 sampled residents (Resident 77). 2. Ensure a resident, who had a g-tube, was placed on enhanced barrier precautions (EBP - an infection control method that uses targeted gown and gloves to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial [a substance that kills microorganisms such as bacteria or mold, or stops them from growing and causing disease agents]) for one of 34 sampled residents (Resident 278). [...]
Inspectors wroteBased on interview and record review, the facility failed to transmit a resident's Discharge Minimum Data Set (MDS - a standardized assessment and care screening tool) within 14 days after the Discharge MDS completion date for one of 34 sampled residents (Resident 55). This deficient practice had the potential to delay care and services for the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 27 out of 55 resident rooms met the square footage requirement of 80 square feet (sq ft- unit of measure) per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained residents' dignity by failing to ensure the urinary drainage bag (a bag that collects the urine drained from the bladder via a catheter [a tube inserted into the bladder to allow urine to drain freely]) was covered with a privacy bag for two of three sampled residents. (Resident 2 and Resident 3) This deficient practice had the potential to negatively affect residents' psychosocial wellbeing and loss of dignity.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift was posted daily as indicated in the facility's policy and procedure (P&P) on Nurse Staffing Information. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by the staff in the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure two of three sampled resident's (Resident 2 and Resident 3) urinary drainage bags were not touching the floor. This deficient practice had the potential for contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of the urinary bag which may in turn cause infection.
Inspectors wroteBased on interview and record review, the facility failed to ensure that three of three sampled residents (Resident 2, Resident 3, and Resident 4) were not prescribed permethrin cream (a medication used to treat scabies [a condition caused by tiny insects called mites] that infest and irritate a person's skin) and ivermectin (a medication that treats infections caused by roundworms, threadworms, and other parasites [organism that lives on or in a host organism and gets its food from or at the expense of its host]); medications used to treat scabies, to treat the residents' diagnosis of pruritus (itchiness). This deficient practice had the potential to result in the use of unnecessary medication and cause adverse side effects (an undesired harmful effect resulting from a medication or other intervention).
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for two of three sampled residents (Resident 2 and Resident 4). This deficient practice resulted in Resident 2 and Resident 4 having long, untrimmed fingernails that had the potential to result in a negative impact on the resident's self-esteem and self-worth.
Inspectors wroteBased on interview and record review, the facility failed to ensure the peripheral (the arms, hands, legs, and feet) intravenous (IV- into the vein) catheter (a thin plastic tube inserted into a vein using a needle) policy was implemented to provide safe care to prevent complications for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for developing complications such as inflammation of the vein and infection.
Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse 1 (RN 1) administered medication as ordered by the physician for one of six sampled residents (Resident 1). This deficient practice had the potential to result in a delay of necessary care and treatment and could lead to adverse health outcome for Resident 1.
Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure on abuse (willful infliction of injury with resulting physical harm, pain or mental anguish) for one of three sampled residents (Resident 5) when on 12/8/2023 at approximately 10:45 a.m. Resident 5 reported an allegation of verbal abuse that occurred on 12/7/2023. The facility failed to: 1. provide documented evidence that a Situation, Background, Assessment and Recommendation (SBAR - a communication tool that helps provide essential, concise information about the condition of a resident) Form was completed. 2. ensure Resident 5 was monitored every shift for 72 hours for emotional distress or negative outcome as a result of the alleged verbal abuse. These deficient practices could have resulted in Resident 2 needing care or emotional support which was not provided.
Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) to address the use of a long arm splint (device applied for elbow and forearm injuries to limit movement of the elbow) for one of three sampled residents (Resident 3). This deficient practice had the potential outcome to have a negative effect on Resident 3's quality of life, as well as the quality of care and services received.
Inspectors wroteBased on interview and record review, the facility failed to ensure that one of two sampled residents (Resident 3) received prescribed pain medication as ordered by the physician. This deficient practice of not administering pain medications as prescribed may lead to inadequate management of resident's pain.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light system (a tool that allows residents to communicate with nurses that they need assistance) was in good working condition for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a delay in nursing care and service for Resident 1.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' call lights were placed within reach for two of five sampled residents (Resident 1 and Resident 2). This deficient practice placed the residents at risk of inability to summon health care workers as needed to receive assistance that may include urgent care.
Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was provided Restorative Nursing Assistant (RNA- specially trained Certified Nursing Assistant who use specialized techniques to maintain and improve each resident's abilities and functions) services as ordered. This deficient practice had the potential to result in a decline in range of motion (ROM) for Resident 1.
Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided the correct x-ray (imaging study that takes pictures of bones and tissues inside the body) as order by the physician. Resident 1 had an order for a left hip x-ray on 9/1/2023, however a chest x-ray was competed. This deficient practice had the potential in a delay in necessary care and services.
13 fire safety citations on file: 1 on July 16, 2026, 9 on June 19, 2025, 3 on July 11, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| July 11, 2024 | Fine | $102,986 |
| July 11, 2024 | Payment Denial | 404 days from August 9, 2024 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | California | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.58 | 4.52 | 3.86 |
| Registered nurses | 0.91 | 0.67 | 0.69 |
| All nursing staff on weekends | 4.36 | 4.09 | 3.42 |
| Nurse aides | 2.52 | ||
| Licensed practical nurses | 1.14 | ||
| Nursing staff turnover (share who left in a year) | 29.9% | 36.7% | 45.8% |
| Registered nurse turnover | 25.9% | 38.1% | 42.9% |
| Administrators who left | 0 |
CMS expects 5.13 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.67 on weekdays and 4.36 on weekends, 7% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 2.9% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.64 in April to June 2025 to 4.58 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.58 | 0.91 | 4.67 | 4.36 | 2.9% | 0 of 90 | 127 |
| Oct to Dec 2025 | 4.58 | 0.87 | 4.67 | 4.35 | 2.7% | 0 of 92 | 130 |
| Jul to Sep 2025 | 4.58 | 0.81 | 4.69 | 4.29 | 2.7% | 0 of 92 | 132 |
| Apr to Jun 2025 | 4.64 | 0.83 | 4.76 | 4.36 | 3.4% | 0 of 91 | 125 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| California, Jan to Mar 2026 | 4.36 | 0.59 | 4.52 | 3.97 | 2.3% | 0.5% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| California, all employers | |||
| CNAs (nursing assistants) | $22.90 | $22.04 to $26.35 | 110,060 |
| LPNs and LVNs | $38.34 | $35.98 to $45.06 | 82,850 |
| Registered nurses | $67.44 | $58.87 to $83.25 | 338,940 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | California | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 7.3 | 10.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.2 | 1.2 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.3 | 1.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.6 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 9.1 | 9.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.9 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 5.7 | 12.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 30.3 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.2 | 11.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.7 | 2.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.3 | 1.6 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for The Rehabilitation Center of North Hills's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (47.6% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
47.6% this home
No different from the national rate
US median of homes 51.5% · California: 301 better, 190 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 121 eligible stays.
10.6% this home
No different from the national rate
US median of homes 10.7% · California: 10 better, 22 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 101 eligible stays.
8.4% this home
No different from the national rate
US median of homes 7.1% · California: 8 better, 48 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 49 eligible stays.
46.1% this home
Median of homes: California59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 39 residents counted.
1.3% this home
Median of homes: California0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 80 residents counted.
0.8% this home
Median of homes: California0.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 80 residents counted.
100.0% this home
Median of homes: California96.2% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 21 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: NORTH HILLS HEALTHCARE & WELLNESS CENTRE LP. CMS links this home to Pursue Health, a group of 7 nursing homes averaging 2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Pursue Health LLC | Operational/managerial control | Organization | 10/31/2014 | |
| Esquivel, Xavier | Operational/managerial control | Individual | 02/01/2023 | |
| Lynch, Jose | Operational/managerial control | Individual | 08/01/2014 | |
| Rutherford, Keino | Operational/managerial control | Individual | 08/02/2025 | |
| North Hills Wellness Gp LLC | General partnership interest | Organization | 08/01/2014 | |
| Lynch, Jose | Limited partnership interest | Individual | 08/01/2014 | |
| Rechnitz, Shlomo | Limited partnership interest | Individual | 08/01/2014 | |
| North Hills-Let LLC | Adp of the SNF | Organization | 03/19/2025 | |
| Pursue Health LLC | Adp of the SNF | Organization | 04/23/2025 | |
| Esquivel, Xavier | Adp of the SNF | Individual | 02/01/2023 | |
| Lynch, Jose | Adp of the SNF | Individual | 08/01/2014 | |
| Rutherford, Keino | Adp of the SNF | Individual | 08/02/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
Licensed assisted living homes in the same town or within 5 miles, each with its California inspection record.
These are the official offices in California. NursingHomeClear cannot take or act on complaints.