Cycle 1
Health 2025-02-09 · Fire 2025-02-09
20 health deficiencies
Top issue: Resident Rights (7 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
San Dimas, CA
Bayshire San Dimas Post-Acute
3-star overall rating with 2-star inspections with $85,083 in total fines with 20 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1740 S San Dimas Ave, San Dimas, CA
(909) 394-0304
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bayshire Senior Communities
Operator or chain grouping
Approved since
1999-05-05
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
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
0.60
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.48
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.36
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.31
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.60
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,376
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.22
Baseline 21.75% · Performance 20.00% · Measure score 3.22 · Achievement 3.10 · Improvement 3.22
Healthcare-associated infections
0.56
Baseline 8.79% · Performance 8.38% · Measure score 0.56 · Achievement 0 · Improvement 0.56
Total nurse turnover
0
Baseline 58.97% · Performance 62.50% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.01% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 10.99% · Lower 95% interval 7.52% |
| Discharge to community | 62.24% |
50.57%
11.7 pts better
|
Better than the National Rate · Eligible stays 85 · Observed rate 60% · Lower 95% interval 50.92% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.78% |
95.27%
2.5 pts better
|
Numerator 88 · Denominator 90 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 90 |
| Discharge self-care score | 77.61% |
53.69%
23.9 pts better
|
Numerator 52 · Denominator 67 |
| Discharge mobility score | 71.64% |
50.94%
20.7 pts better
|
Numerator 48 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 90 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.38% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 10.53% · Lower 95% interval 5.11% |
| Staff COVID-19 vaccination coverage | 21.28% |
8.2%
13.1 pts better
|
Numerator 10 · Denominator 47 |
| Staff flu vaccination coverage | 39.51% |
42%
2.5 pts worse
|
Numerator 32 · Denominator 81 |
| Discharge function score | 53.73% |
56.45%
2.7 pts worse
|
Numerator 36 · Denominator 67 |
| Transfer of health information to provider | 90.91% |
95.95%
5 pts worse
|
Numerator 20 · Denominator 22 |
| Transfer of health information to patient | 98.11% |
96.28%
1.8 pts better
|
Numerator 52 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 13.73% |
25.2%
11.5 pts worse
|
Numerator 7 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 0.0% |
13.7%
13.7 pts better
|
19.6%
19.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| 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 · 4Q avg 0.0% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
94.0%
5.8 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.8% |
11.2%
8.4 pts better
|
12.0%
9.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.8% · Observed 2.5% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
93.2%
6.3 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
23.2%
1.2 pts better
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 17.7% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-29 · Fire 2024-01-29
22 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2021-12-02 · Fire 2021-12-02
18 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-09
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2025-03-06
C · Minimal harm
2025-02-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-02-28
F · Potential for more than minimal harm
2024-01-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-01-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-01-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-01-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-29
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 2024-02-22
D · Potential for more than minimal harm
2024-01-29
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-22
C · Minimal harm
2024-01-29
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-02-22
F · Potential for more than minimal harm
2021-12-02
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-02-07
F · Potential for more than minimal harm
2021-12-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-02-07
F · Potential for more than minimal harm
2021-12-02
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-02-07
F · Potential for more than minimal harm
2021-12-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-02-07
D · Potential for more than minimal harm
2021-12-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-02-07
D · Potential for more than minimal harm
2021-12-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-02-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-11
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 2026-01-05
D · Potential for more than minimal harm
2025-12-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-11
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 2026-01-05
D · Potential for more than minimal harm
2025-12-11
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 2026-01-05
D · Potential for more than minimal harm
2025-12-11
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 2026-01-05
D · Potential for more than minimal harm
2025-12-11
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 2026-01-05
D · Potential for more than minimal harm
2025-08-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-02-09
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 2025-03-05
E · Potential for more than minimal harm
2025-02-09
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 2025-02-20
D · Potential for more than minimal harm
2025-02-09
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 2025-03-05
D · Potential for more than minimal harm
2025-02-09
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 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
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 2025-03-05
D · Potential for more than minimal harm
2025-02-09
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 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
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 2025-03-05
D · Potential for more than minimal harm
2025-02-09
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 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-03-05
G · Actual harm
2024-11-06
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 2024-11-26
E · Potential for more than minimal harm
2024-11-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-07-18
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-18
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-18
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-18
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 2024-08-27
D · Potential for more than minimal harm
2024-06-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-26
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-07-19
G · Actual harm
2024-01-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-01-29
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-01-29
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 2024-02-25
E · Potential for more than minimal harm
2024-01-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-01-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-01-29
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-01-29
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-29
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-29
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 2024-02-25
D · Potential for more than minimal harm
2024-01-29
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-29
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 2024-02-25
D · Potential for more than minimal harm
2023-10-27
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 2023-10-27
E · Potential for more than minimal harm
2023-05-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-16
H · Actual harm
2023-03-15
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 2023-04-13
E · Potential for more than minimal harm
2023-03-15
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 2023-04-13
E · Potential for more than minimal harm
2021-12-02
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 2022-02-09
E · Potential for more than minimal harm
2021-12-02
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 2022-02-09
E · Potential for more than minimal harm
2021-12-02
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 2022-02-09
E · Potential for more than minimal harm
2021-12-02
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 2022-02-09
E · Potential for more than minimal harm
2021-12-02
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 2022-02-09
E · Potential for more than minimal harm
2021-12-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-09
D · Potential for more than minimal harm
2021-12-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-02-09
D · Potential for more than minimal harm
2021-12-02
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-02-09
D · Potential for more than minimal harm
2021-12-02
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 2022-02-09
D · Potential for more than minimal harm
2021-12-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-02-09
D · Potential for more than minimal harm
2021-12-02
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 2022-02-09
D · Potential for more than minimal harm
2021-12-02
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 2022-02-09
B · Minimal harm
2021-12-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-02-09
Penalties and ownership
What sits behind the stars
$12,048
2024-11-06
Fine
Fine · fine $12,048
Fine
$4,938
2024-02-20
Fine
Fine · fine $4,938
Fine
$4,938
2024-02-12
Fine
Fine · fine $4,938
Fine
$25,058
2024-01-29
Fine
Fine · fine $25,058
Fine
$14,814
2024-01-22
Fine
Fine · fine $14,814
Fine
$4,938
2024-01-08
Fine
Fine · fine $4,938
Fine
$4,587
2024-01-02
Fine
Fine · fine $4,587
Fine
$13,762
2023-12-11
Fine
Fine · fine $13,762
Fine
Ownership
Kirby, Scott
Operational/Managerial Control · Individual
Kirby, Scott
Corporate Officer · Individual
Peterson, Tanner
Operational/Managerial Control · Individual
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