Cycle 1
Health 2025-01-31 · Fire 2025-01-31
64 health deficiencies
Top issue: Resident Assessment and Care Planning (13 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Los Angeles, CA
Avalon Villa Care Center
1-star overall rating with 1-star inspections with Special Focus status with $66,612 in total fines with 64 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
12029 Avalon Blvd, Los Angeles, CA
(323) 756-8191
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
131
Certified beds
Average residents
118
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1968-11-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.37
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.95
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,866
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9953
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.45
Baseline 23.02% · Performance 21.25% · Measure score 2.45 · Achievement 0 · Improvement 2.45
Healthcare-associated infections
7.79
Baseline 9.29% · Performance 5.73% · Measure score 7.79 · Achievement 7.05 · Improvement 7.79
Total nurse turnover
2.98
Baseline 45.59% · Performance 51.49% · Measure score 2.98 · Achievement 2.98 · Improvement 0
Adjusted total nurse staffing
3.72
Baseline 4.44 hours · Performance 4.14 hours · Measure score 3.72 · Achievement 3.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.66% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 139 · Observed rate 14.39% · Lower 95% interval 8.22% |
| Discharge to community | 34.32% |
50.57%
16.2 pts worse
|
Worse than the National Rate · Eligible stays 75 · Observed rate 25.33% · Lower 95% interval 25.97% |
| Medicare spending per beneficiary | 1.61 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 96.93% |
95.27%
1.7 pts better
|
Numerator 158 · Denominator 163 |
| Falls with major injury | 0.61% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 163 |
| Discharge self-care score | 76.62% |
53.69%
22.9 pts better
|
Numerator 59 · Denominator 77 |
| Discharge mobility score | 68.83% |
50.94%
17.9 pts better
|
Numerator 53 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 0.61% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 163 · Adjusted rate 0.44% |
| Healthcare-associated infections requiring hospitalization | 5.73% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 135 · Observed rate 4.44% · Lower 95% interval 3.73% |
| Staff COVID-19 vaccination coverage | 24.46% |
8.2%
16.3 pts better
|
Numerator 45 · Denominator 184 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 71.43% |
56.45%
15 pts better
|
Numerator 55 · Denominator 77 |
| Transfer of health information to provider | 89.39% |
95.95%
6.6 pts worse
|
Numerator 59 · Denominator 66 |
| Transfer of health information to patient | 65.22% |
96.28%
31.1 pts worse
|
Numerator 15 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 35.71% |
25.2%
10.5 pts better
|
Numerator 30 · Denominator 84 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.6 |
2.3
2.3 pts worse
|
1.9
2.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.6 · Observed 6.4 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.7 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.4% |
98.5%
14.1 pts worse
|
93.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.9% · Q2 81.3% · Q3 87.0% · Q4 87.5% · 4Q avg 84.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
98.2%
0.9 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
1.6%
0.9 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 1.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.4% |
6.8%
1.6 pts worse
|
11.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 6.4% · Q3 16.2% · Q4 6.7% · 4Q avg 8.4% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
4.1%
0.1 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 7.4% · Q4 5.2% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
13.7%
4.1 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 9.9% · Q3 9.3% · Q4 8.0% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.8% |
14.2%
6.4 pts better
|
16.7%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 6.1% · Q3 5.6% · Q4 7.8% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.6% |
11.0%
4.6 pts worse
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 23.6% · Q3 0.0% · Q4 15.1% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.9% |
10.7%
3.2 pts worse
|
14.9%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 18.4% · Q3 13.9% · Q4 10.4% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.0%
0.6 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 0.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.2%
0.4 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.5% |
10.9%
7.4 pts better
|
19.8%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 6.4% · Q3 5.2% · Q4 0.0% · 4Q avg 3.5% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.7%
1.5 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.3% · Q3 1.1% · Q4 2.8% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.4% |
94.0%
15.6 pts worse
|
81.7%
3.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 54.3% · Q2 64.6% · Q3 91.9% · Q4 100.0% · 4Q avg 78.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
11.2%
5.5 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 6.8% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.5%
0.9 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 5.3% · Q4 2.5% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.3% |
93.2%
29.9 pts worse
|
79.7%
16.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.7% |
23.2%
6.5 pts worse
|
23.9%
5.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.7% · Observed 30.8% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-29 · Fire 2023-12-29
27 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2021-04-23 · Fire 2021-04-23
29 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-01-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-01-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-31
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-02-17
F · Potential for more than minimal harm
2023-12-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-29
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-29
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-29
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-29
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-29
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-29
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-29
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2024-01-23
C · Minimal harm
2023-12-29
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-01-23
C · Minimal harm
2023-12-29
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-01-23
D · Potential for more than minimal harm
2021-04-23
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2021-06-02
D · Potential for more than minimal harm
2021-04-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-06-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-09
D · Potential for more than minimal harm
2025-12-23
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-23
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-23
F907 · Environmental Deficiencies
Health
Provide enough space and equipment to meet each resident's needs
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-12
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-11-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-09-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-09
D · Potential for more than minimal harm
2025-09-19
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-10-09
F · Potential for more than minimal harm
2025-09-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-04
F · Potential for more than minimal harm
2025-09-11
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-10-04
D · Potential for more than minimal harm
2025-09-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-10-04
D · Potential for more than minimal harm
2025-09-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-10-04
E · Potential for more than minimal harm
2025-08-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-19
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-19
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-06
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-08-24
D · Potential for more than minimal harm
2025-08-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-24
D · Potential for more than minimal harm
2025-08-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-24
D · Potential for more than minimal harm
2025-08-06
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-08-24
D · Potential for more than minimal harm
2025-07-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-21
D · Potential for more than minimal harm
2025-07-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-21
D · Potential for more than minimal harm
2025-06-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-08
D · Potential for more than minimal harm
2025-05-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-08
D · Potential for more than minimal harm
2025-04-16
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-02-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-25
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-03-25
J · Immediate jeopardy
2025-01-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-24
F · Potential for more than minimal harm
2025-01-31
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2025-02-24
F · Potential for more than minimal harm
2025-01-31
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-02-24
F · Potential for more than minimal harm
2025-01-31
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-02-24
F · Potential for more than minimal harm
2025-01-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-31
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-31
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-02-24
D · Potential for more than minimal harm
2024-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-04
G · Actual harm
2024-01-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-24
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-23
F · Potential for more than minimal harm
2023-12-29
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-01-28
E · Potential for more than minimal harm
2023-12-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-28
E · Potential for more than minimal harm
2023-12-29
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-01-28
E · Potential for more than minimal harm
2023-12-29
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-01-28
E · Potential for more than minimal harm
2023-12-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-28
E · Potential for more than minimal harm
2023-12-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-01-28
E · Potential for more than minimal harm
2023-12-29
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-01-28
E · Potential for more than minimal harm
2023-12-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-28
E · Potential for more than minimal harm
2023-12-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-28
E · Potential for more than minimal harm
2023-12-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-29
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-29
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-29
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-29
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-01
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-31
D · Potential for more than minimal harm
2023-11-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-18
D · Potential for more than minimal harm
2023-10-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-09-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-21
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-08-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-08-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-15
G · Actual harm
2021-04-23
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2021-06-03
F · Potential for more than minimal harm
2021-04-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-06-03
F · Potential for more than minimal harm
2021-04-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-06-03
E · Potential for more than minimal harm
2021-04-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-06-03
E · Potential for more than minimal harm
2021-04-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-06-03
E · Potential for more than minimal harm
2021-04-23
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2021-06-03
E · Potential for more than minimal harm
2021-04-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-04-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-04-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-04-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-04-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-04-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-04-23
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-04-23
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-04-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-04-23
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-06-03
Penalties and ownership
What sits behind the stars
$41,457
2025-01-31
Fine
Fine · fine $41,457
Fine
$0
2025-01-31
Payment Denial
Payment Denial · denial start 2025-03-01 · 24 days
24 day denial
$25,155
2023-10-16
Fine
Fine · fine $25,155
Fine
$0
2023-10-16
Payment Denial
Payment Denial · denial start 2024-01-16 · 38 days
38 day denial
Ownership
Jacobs, Harry
5% Or Greater Direct Ownership Interest · Individual
Jacobs, Harry
Operational/Managerial Control · Individual
Jacobs, Harry
Corporate Officer · Individual
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