Health inspection·October 24, 2025

California Code, Health and Safety Code - HSC § 1418.21 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations in the facility: (A) An area accessible and visible to members of the public. (B) An area used for employee breaks. (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities. (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (C) The most recent overall star rating given by CMS to that facility, except that a facility shall have seven business days from the date when it receives a different rating from CMS to include the updated rating in the posting. The star rating shall be aligned in the center of the page. The star rating shall be expressed as the number that reflects the number of stars given to the facility by CMS. The number shall be in a clear and easily readable font of at least two inches print. (4) The requirements of this section shall be in addition to any other posting or inspection report availability requirements. (b) Violation of this section shall constitute a class B violation, as defined in subdivision (e) of Section 1424 and, notwithstanding Section 1290, shall not constitute a crime. Fines from a violation of this section shall be deposited into the State Health Facilities Citation Penalties Account, created pursuant to Section 1417.2. On 10/7/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its relicensing survey. The facility failed to post the current Center for Medicare and Medicaid System (CMS- the federal agency that provides health coverage) star rating (CMS created the Five-Star Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily and to help identify areas about which you may want to ask questions. The Nursing Home Care Compare web site features a quality rating system that gives each nursing home a rating of between one and five stars. Nursing homes with 5 stars are considered to have much above average quality and nursing homes with 1 star are considered to have quality much below average) signage on 10/7/2025. This failure had the potential to result in the dissemination of incorrect or outdated information to the public. During an observation on 10/7/2025, at 9:35 a.m., in the facility’s front lobby, a three-star rating was observed posted on the wall just outside the Administrator’s (ADM) office. During a review of the CMS website for star rating dated 9/24/2025 indicated the facility had an overall two-star rating. During an observation on 10/8/2025, at 7:30 a.m., in the facility’s front lobby, a three-star rating remained posted on the wall just outside the ADM’s office. During an observation on 10/9/2025, at 7:34 a.m., in the facility’s front lobby, a three-star rating was still posted on the wall just outside of the ADM’s office. During concurrent interview and record review on 10/9/2025, at 10:16 a.m., with the ADM, the “All Facilities Letter (AFL- a communication from the California Department of Public Health [CDPH] to health facilities regarding changes or guidance affecting their operations) 10-05, dated 2/26/2010, last updated on 10/6/2017, was reviewed. The AFL 10-05 indicated, “Effective 1/1/2011, Health and Safety Code (HSC - a set of regulations for maintaining public and workplace health and safety) Section 1418.21 requires that a skilled nursing facility that has been certified for purposes of Medicare or Medicaid post the overall facility rating information determined by the federal CMS in accordance with the following requirements: 1. The information shall be posted in at least the following locations in the facility: (A) An area accessible and visible to members of the public. (B) An area used for employee breaks. (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities. 2. The information shall be posted on white or light-colored paper that includes all of the following, in the following order: … (C) The most recent overall star rating given by CMS to that facility, except that a facility shall have seven business days from the date when it receives a different rating from the CMS to include the updated rating in the posting… The star rating shall be expressed as the number that reflects the number of stars given to the facility by the CMS… Violation of this section shall constitute a class B violation (a violation of a regulation that has a direct relationship to the health, safety, or security of individuals), as defined in subdivision (e) of HSC Section 1424. The ADM stated that the Minimum Data Set Nurse (MDSN) was in charge of changing the star rating signage whenever CMS releases a new rating. The ADM stated MDSN should change the star rating signage the same day the updated star rating is released. The ADM further stated that the importance of the star rating signage was to inform the public of higher quality reports. The ADM stated that the most recent CMS report released on 9/24/2025 indicated the facility had a two-star rating. The ADM stated that more than seven days had passed since the CMS released the new rating, and the facility had not yet updated the signage. The ADM stated that the facility did not follow the AFL. During a concurrent interview, and record review on 10/9/2025, at 1:11 p.m., with the Minimum Data Set Nurse Coordinator (MDSNC), the facility’s star rating results were reviewed and resulted as follows: 1. 9/16/2025- two-stars 2. 7/22/2025- two-stars 3. 6/17/2025- two-stars The MDSNC stated that it is her (MDSNC) department’s responsibility to update the star rating signage quarterly (every three months). The MDSNC stated that she (MDSNC) was not able to update the star rating. The MDSNC stated that accurate star rating signage provides important information to the public. The MDSNC stated that posting a higher star rating than the facility’s actual rating constitutes false information, which could be misleading and confuse residents and their families. The MDSNC stated that the star rating can influence a resident’s or family’s decision to remain at the facility. The MDSNC stated that this morning (10/9/2025) she (MDSNC) received a call from Minimum Data Set Nurse 1 (MDSN 1) regarding how to print the latest star rating, and that MDSN 1 updated the star rating signage that same day (10/9/2025). During an interview on 10/9/2025, at 1:50 p.m., with MDSN 1, MDSN 1 stated that he (MDSN 1) checked the CMS website today (10/9/2025) and found out that an updated star rating had been released on 9/19/2025, indicating the facility had a two-star rating. MDSN 1 stated that as of that morning (10/9/2025), the signage still displayed a three-star rating, which he (MDSN 1) changed to two-stars at 8:00 a.m. MDSN 1 further stated that a two-star rating signifies the facility needs further improvement and progress. MDSN 1 stated that posting the incorrect star rating could misinform residents and families and potentially influence their decisions to remain at the facility. During an interview on 10/10/2025, with the Director of Nursing (DON), the DON stated that posting accurate star ratings is important to ensure consumers, families and residents have correct information. The DON stated that it is the ADM’s responsibility to ensure the star rating signage is updated. The DON further stated that posting a higher star rating than the facility’s actual rating could deceive residents and families and reflect dishonesty on the part of the facility. The DON stated that the facility did not follow the AFL regulation. The facility failed to post the current CMS star rating signage on 10/7/2025. This failure had the potential to result in the dissemination of incorrect or outdated information to the public. The above violation had a direct relationship to the health, safety, or security of the residents at the facility.