Nursing Care Index

Mirage Post Acute

Lancaster, Los Angeles County, California · CCN 056039 · For-profit (Partnership) · part of Pacs Group (274 facilities, chain average 2.9 stars)

CMS rates Mirage Post Acute 1 of 5 overall as of August 2026. 299 certified beds, 268 residents a day on average. 275 citations on record from the current inspection cycles, 3 at immediate jeopardy; 3 fines totalling $153,991.

On record

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★☆☆☆☆ 1 of 5
Health inspections★☆☆☆☆ 1 of 5
Staffing★★☆☆☆ 2 of 5
Quality measures★★★☆☆ 3 of 5
Quality: long-stay / short-stay5 / 2 of 5

Staffing

Total nurse staffing4.56176 hours per resident per day
Registered nurses0.36859 hours per resident per day
Weekend total4.06862 hours per resident per day
Nursing staff turnover50.4% (registered nurses 55.2%)
Administrators who left2

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-07-01
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-07-16
2026-07-01
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-07-16
2026-07-01
complaint survey		 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-16
2026-07-01
complaint survey		 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · tag F0641		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-16
2026-07-01
complaint survey		 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-16
2026-07-01
complaint survey		 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-16
2026-07-01
complaint survey		 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-16
2026-06-17
complaint survey		 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-08
2026-06-17
complaint survey		 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Administration Deficiencies · tag F0849		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-08
2026-06-13
complaint survey		 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · tag F0584		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-07-02
2026-06-13
complaint survey		 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-07-02
2026-06-09
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-06-23
2026-06-09
complaint survey		 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-23
2026-06-09
complaint survey		 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-23
2026-06-09
complaint survey		 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies · tag F0628		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-23
2026-06-09
complaint survey		 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-23
2026-06-09
complaint survey		 Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-23
2026-06-09
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-23
2026-06-09
complaint survey		 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-23
2026-06-09
complaint survey		 Implement a program that monitors antibiotic use.
Infection Control Deficiencies · tag F0881		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-23
2026-06-02
complaint survey		 Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Resident Rights Deficiencies · tag F0627		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-18
2026-05-29
complaint survey		 Give the resident's representative the ability to exercise the resident's rights.
Resident Rights Deficiencies · tag F0551		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-12
2026-05-22
complaint survey		 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-05
2026-05-22
complaint survey		 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-05
2026-05-22
complaint survey		 Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-05
2026-04-28
complaint survey		 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-11
2026-04-28
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-11
2026-04-24 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies · tag F0578		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-05-15
2026-04-24 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-05-15
2026-04-24 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-05-15
2026-04-24 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-05-15
2026-04-24 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-05-15
2026-04-24 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-05-15
2026-04-24 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Quality of Life and Care Deficiencies · tag F0700		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-05-15
2026-04-24 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-05-15
2026-04-24 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Nutrition and Dietary Deficiencies · tag F0803		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-05-15
2026-04-24 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-05-15
2026-04-24 Implement a program that monitors antibiotic use.
Infection Control Deficiencies · tag F0881		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-05-15
2026-04-24 Keep all essential equipment working safely.
Environmental Deficiencies · tag F0908		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-05-15
2026-04-24 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-15
2026-04-24 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · tag F0584		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-15
2026-04-24 Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0605		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-15
2026-04-24 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-15
2026-04-24 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · tag F0657		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-15
2026-04-24 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-15
2026-04-24 Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies · tag F0685		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-15
2026-04-24 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies · tag F0688		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-15
2026-04-24 Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-15
2026-04-24 Provide routine and 24-hour emergency dental care for each resident.
Quality of Life and Care Deficiencies · tag F0790		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-15
2026-04-24 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-15
2026-03-06
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-16
2026-02-02
complaint survey		 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies · tag F0921		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-02-04
2026-01-30
complaint survey		 Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0605		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-03-02
2026-01-30
complaint survey		 Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-03-02
2026-01-30
complaint survey		 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-02
2026-01-30
complaint survey		 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-02
2026-01-30
complaint survey		 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-02
2026-01-30
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-02
2026-01-30
complaint survey		 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-02
2026-01-20
complaint survey		 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Environmental Deficiencies · tag F0925		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-02-19
2026-01-20
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-02-19
2025-12-17
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-24
2025-11-25
complaint survey		 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · tag F0657		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-26
2025-11-24
complaint survey		 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-11-25
2025-11-24
complaint survey		 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-11-25
2025-11-24
complaint survey		 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · tag F0584		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-25
2025-11-24
complaint survey		 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-25
2025-09-05
complaint survey		 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-09-26
2025-09-05
complaint survey		 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-26
2025-09-05
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-26
2025-09-05
complaint survey		 Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies · tag F0919		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-26
2025-09-05
complaint survey		 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies · tag F0921		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-26
2025-08-21
complaint survey		 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689		 G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-09-19
2025-08-21
complaint survey		 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Resident Rights Deficiencies · tag F0585		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-19
2025-08-21
complaint survey		 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-19
2025-08-21
complaint survey		 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · tag F0657		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-19
2025-08-21
complaint survey		 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Quality of Life and Care Deficiencies · tag F0693		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-19
2025-08-21
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-19
2025-08-21
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-26
2025-08-07
complaint survey		 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-03
2025-08-07
complaint survey		 Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies · tag F0679		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-03
2025-08-07
complaint survey		 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-03
2025-08-07
complaint survey		 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-03
2025-07-22
complaint survey		 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-28
2025-07-15
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-08-08
2025-07-09
complaint survey		 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-07-31
2025-07-09
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-07-31
2025-07-09
complaint survey		 Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-31
2025-07-09
complaint survey		 Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-31
2025-06-05
complaint survey		 Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-06-23
2025-06-05
complaint survey		 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-06-23
2025-05-16
complaint survey		 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-06-08
2025-05-16
complaint survey		 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-06-08
2025-05-16
complaint survey		 Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-06-08
2025-05-16
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-06-08
2025-04-03
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-04-27
2025-04-03
complaint survey		 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · tag F0584		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-27
2025-04-03
complaint survey		 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-27
2025-04-03
complaint survey		 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-27
2025-04-03
complaint survey		 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-27
2025-04-03
complaint survey		 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-27
2025-03-28
complaint survey		 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580		 J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2025-04-21
2025-03-28
complaint survey		 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600		 J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2025-04-21
2025-03-28
complaint survey		 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684		 J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2025-04-21
2025-03-28
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-21
2025-03-12
complaint survey		 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-04-01
2025-03-12
complaint survey		 Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-01
2025-03-11
complaint survey		 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-13
2025-03-11
complaint survey		 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-13
2025-03-11
complaint survey		 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-13
2025-03-10
complaint survey		 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-30
2025-03-10
complaint survey		 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-30
2025-02-25
complaint survey		 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-28
2025-02-25
complaint survey		 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies · tag F0676		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-28
2025-02-07
complaint survey		 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600		 G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-02-28
2025-02-04
complaint survey		 Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies · tag F0583		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-05
2025-02-04
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-05
2025-01-28
complaint survey		 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Resident Rights Deficiencies · tag F0585		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-30
2025-01-28
complaint survey		 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-30
2025-01-28
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-30
2025-01-22
complaint survey		 Post nurse staffing information every day.
Nursing and Physician Services Deficiencies · tag F0732		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-01-25
2025-01-22
complaint survey		 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-01-25
2025-01-22
complaint survey		 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies · tag F0921		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-01-25
2025-01-17 Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17
complaint survey		 Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies · tag F0694		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Quality of Life and Care Deficiencies · tag F0700		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 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.
Pharmacy Service Deficiencies · tag F0758		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies · tag F0761		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Nutrition and Dietary Deficiencies · tag F0802		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Nutrition and Dietary Deficiencies · tag F0803		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · tag F0804		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies · tag F0805		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Nutrition and Dietary Deficiencies · tag F0808		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies · tag F0814		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-17 Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · tag F0554		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-05
2025-01-17 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · tag F0584		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-05
2025-01-17 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies · tag F0676		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-05
2025-01-17 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-05
2025-01-17 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-05
2025-01-17 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-05
2025-01-17 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Quality of Life and Care Deficiencies · tag F0693		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-05
2025-01-17 PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · tag F0645		 B No actual harm, with potential for minimal harm; pattern Deficient, Provider has date of correction
2025-02-05
2025-01-07
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-20
2025-01-06
complaint survey		 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-01-24
2025-01-06
complaint survey		 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-24
2025-01-06
complaint survey		 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-24
2025-01-06
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-24
2024-12-19
complaint survey		 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-01-09
2024-12-19
complaint survey		 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-09
2024-12-19
complaint survey		 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · tag F0584		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-09
2024-12-19
complaint survey		 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-09
2024-12-12
complaint survey		 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-28
2024-12-06
complaint survey		 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-21
2024-11-25
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-12-16
2024-11-25
complaint survey		 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · tag F0584		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-16
2024-11-25
complaint survey		 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-16
2024-11-15
complaint survey		 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-12
2024-11-15
complaint survey		 Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies · tag F0694		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-12
2024-11-15
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-12
2024-11-14
complaint survey		 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-11-30
2024-11-13
complaint survey		 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-02
2024-11-13
complaint survey		 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-02
2024-11-13
complaint survey		 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-02
2024-11-13
complaint survey		 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-02
2024-11-13
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-02
2024-10-08
complaint survey		 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-21
2024-10-08
complaint survey		 Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies · tag F0679		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-21
2024-10-08
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-21
2024-10-03
complaint survey		 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-22
2024-10-03
complaint survey		 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Quality of Life and Care Deficiencies · tag F0693		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-22
2024-09-28
complaint survey		 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-10-18
2024-09-28
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-10-18
2024-09-28
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-10-18
2024-09-28
complaint survey		 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-18
2024-09-28
complaint survey		 Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-18
2024-09-28
complaint survey		 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Resident Rights Deficiencies · tag F0585		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-18
2024-09-28
complaint survey		 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-18
2024-09-28
complaint survey		 Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies · tag F0679		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-18
2024-09-28
complaint survey		 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-18
2024-09-28
complaint survey		 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Quality of Life and Care Deficiencies · tag F0693		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-18
2024-09-28
complaint survey		 Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-18
2024-09-28
complaint survey		 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-18
2024-09-03
complaint survey		 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-09-23
2024-08-08
complaint survey		 Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies · tag F0552		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-20
2024-08-08
complaint survey		 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-20
2024-07-11
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-07-17
2024-05-06
complaint survey		 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-24
2024-05-06
complaint survey		 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-24
2024-05-06
complaint survey		 Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Nursing and Physician Services Deficiencies · tag F0728		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-24
2024-05-01
complaint survey		 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-10
2024-05-01
complaint survey		 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.
Pharmacy Service Deficiencies · tag F0758		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-10
2024-04-16
complaint survey		 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-25
2024-03-18
complaint survey		 Honor each resident's preferences, choices, values and beliefs.
Quality of Life and Care Deficiencies · tag F0675		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-04
2024-03-18
complaint survey		 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-04
2024-03-18
complaint survey		 Keep all essential equipment working safely.
Environmental Deficiencies · tag F0908		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-04
2024-03-18
complaint survey		 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · tag F0584		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-04
2024-03-18
complaint survey		 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-04
2024-03-18
complaint survey		 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-04
2024-03-18
complaint survey		 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies · tag F0688		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-04
2024-03-18
complaint survey		 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Nutrition and Dietary Deficiencies · tag F0801		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-04
2024-03-18
complaint survey		 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-04
2024-01-26
complaint survey		 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies · tag F0552		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies · tag F0578		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies · tag F0694		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Provide medically-related social services to help each resident achieve the highest possible quality of life.
Quality of Life and Care Deficiencies · tag F0745		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · tag F0756		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 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.
Pharmacy Service Deficiencies · tag F0758		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies · tag F0761		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Administration Deficiencies · tag F0849		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Resident Rights Deficiencies · tag F0553		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26
complaint survey		 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies · tag F0623		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Resident Rights Deficiencies · tag F0625		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies · tag F0655		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · tag F0657		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Plan the resident's discharge to meet the resident's goals and needs.
Resident Assessment and Care Planning Deficiencies · tag F0660		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Quality of Life and Care Deficiencies · tag F0678		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies · tag F0685		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Quality of Life and Care Deficiencies · tag F0693		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0698		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26
complaint survey		 Provide or obtain dental services for each resident.
Quality of Life and Care Deficiencies · tag F0791		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Nutrition and Dietary Deficiencies · tag F0809		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Keep all essential equipment working safely.
Environmental Deficiencies · tag F0908		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-23
2024-01-26 Assess the resident when there is a significant change in condition
Resident Assessment and Care Planning Deficiencies · tag F0637		 B No actual harm, with potential for minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Resident Assessment and Care Planning Deficiencies · tag F0640		 B No actual harm, with potential for minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-26 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · tag F0641		 B No actual harm, with potential for minimal harm; pattern Deficient, Provider has date of correction
2024-02-23
2024-01-11
complaint survey		 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-02
2024-01-11
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-02-02
2024-01-11
complaint survey		 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-02
2024-01-11
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-02
2024-01-11
complaint survey		 Hire a qualified full-time social worker in a facility with more than 120 beds.
Administration Deficiencies · tag F0850		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-02
2024-01-11
complaint survey		 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-02
2023-11-29
complaint survey		 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-12-12
2023-11-29
complaint survey		 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-12
2023-11-29
complaint survey		 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-12
2023-11-29
complaint survey		 Post nurse staffing information every day.
Nursing and Physician Services Deficiencies · tag F0732		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-12
2023-11-07
complaint survey		 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Nutrition and Dietary Deficiencies · tag F0803		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-12-02
2023-11-07
complaint survey		 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · tag F0804		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-12-02
2023-11-07
complaint survey		 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-02
2023-11-07
complaint survey		 Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-02
2023-11-07
complaint survey		 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-02
2023-11-01
complaint survey		 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-11-16
2023-11-01
complaint survey		 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-16
2023-11-01
complaint survey		 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-16
2023-10-29
complaint survey		 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-20
2023-10-29
complaint survey		 Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Administration Deficiencies · tag F0773		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-20
2023-10-29
complaint survey		 Report COVID19 data to residents and families.
Infection Control Deficiencies · tag F0885		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-20
2023-10-17
complaint survey		 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · tag F0584		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-02
2023-10-17
complaint survey		 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Resident Rights Deficiencies · tag F0585		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-02
2023-10-05
complaint survey		 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689		 D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-17
2023-09-13
complaint survey		 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880		 E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-10-13
2023-09-13
complaint survey		 Post nurse staffing information every day.
Nursing and Physician Services Deficiencies · tag F0732		 B No actual harm, with potential for minimal harm; pattern Deficient, Provider has date of correction
2023-10-13

Fines and payment denials

DatePenaltyAmount
2025-07-22Fine$36,377
2025-03-10Fine$99,263
2025-02-07Fine$18,351

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Apt, Frederick
Individual		corporate officer—2023-06-15
Hancock, Mark
Individual		corporate officer—2023-06-15
Mitchell, John
Individual		corporate officer—2023-06-15
Murray, Jason
Individual		corporate officer—2023-06-15
Jack, Spencer
Individual		operational/managerial control—2023-06-15
Jack, Spencer
Individual		w-2 managing employee—2023-06-15

What changed

Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Los Angeles County.