Cycle 1
Health 2026-01-08 · Fire 2026-01-08
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Santa Monica, CA
Berkley West Healthcare Center
3-star overall rating with 2-star inspections with $101,046 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1623 Arizona Avenue, Santa Monica, CA
(310) 829-4565
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
54
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aspen Skilled Healthcare
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
34 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 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
0.77
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.17
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.18
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.94
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.59
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,576
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.03
Baseline 19.84% · Performance 20.49% · Measure score 2.03 · Achievement 2.03 · Improvement 0
Healthcare-associated infections
2.83
Baseline 6.58% · Performance 6.99% · Measure score 2.83 · Achievement 2.83 · Improvement 0
Total nurse turnover
3.10
Baseline 44.83% · Performance 51.02% · Measure score 3.10 · Achievement 3.10 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.83 hours · Performance 2.36 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.58% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 288 · Observed rate 11.81% · Lower 95% interval 9.1% |
| Discharge to community | 66.6% |
50.57%
16 pts better
|
Better than the National Rate · Eligible stays 258 · Observed rate 59.3% · Lower 95% interval 58.88% |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 176 · Denominator 176 |
| Falls with major injury | 0.57% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 176 |
| Discharge self-care score | 36.54% |
53.69%
17.1 pts worse
|
Numerator 38 · Denominator 104 |
| Discharge mobility score | 46.15% |
50.94%
4.8 pts worse
|
Numerator 48 · Denominator 104 |
| Pressure ulcers or injuries, new or worsened | 0.57% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 176 · Adjusted rate 0.46% |
| Healthcare-associated infections requiring hospitalization | 6.99% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 178 · Observed rate 6.74% · Lower 95% interval 4.67% |
| Staff COVID-19 vaccination coverage | 8.33% |
8.2%
0.1 pts better
|
Numerator 5 · Denominator 60 |
| Staff flu vaccination coverage | 47.76% |
42%
5.8 pts better
|
Numerator 32 · Denominator 67 |
| Discharge function score | 45.19% |
56.45%
11.3 pts worse
|
Numerator 47 · Denominator 104 |
| Transfer of health information to provider | 96.23% |
95.95%
0.3 pts better
|
Numerator 51 · Denominator 53 |
| Transfer of health information to patient | 99.14% |
96.28%
2.9 pts better
|
Numerator 115 · Denominator 116 |
| Resident COVID-19 vaccinations up to date | 29.79% |
25.2%
4.6 pts better
|
Numerator 28 · Denominator 94 |
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 | 4.8% |
1.6%
3.2 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.0% |
6.8%
1.8 pts better
|
11.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
13.7%
1.2 pts better
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
14.2%
3.1 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 0.0% |
11.0%
11 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
10.7%
8.3 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.6% |
10.9%
16.7 pts worse
|
19.8%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.6% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.7%
2.2 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.3% |
11.2%
2.1 pts worse
|
12.0%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 12.5% · Expected 10.5% · 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 0.8% · Q3 0.8% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
93.2%
1.2 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.0% |
23.2%
2.2 pts better
|
23.9%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 19.6% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-10 · Fire 2024-11-10
33 health deficiencies
Top issue: Resident Rights (7 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-10-16 · Fire 2023-10-16
35 health deficiencies
Top issue: Resident Assessment and Care Planning (10 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2026-02-11
F · Potential for more than minimal harm
2026-01-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-11
E · Potential for more than minimal harm
2026-01-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-08
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 2026-02-11
D · Potential for more than minimal harm
2026-01-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-02-11
E · Potential for more than minimal harm
2024-11-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-10
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-03
F · Potential for more than minimal harm
2023-10-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-10-16
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-11-18
D · Potential for more than minimal harm
2023-10-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-18
D · Potential for more than minimal harm
2023-10-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-08
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 2026-02-06
D · Potential for more than minimal harm
2026-01-08
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 2026-02-06
D · Potential for more than minimal harm
2026-01-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-08
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-06-20
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-03
E · Potential for more than minimal harm
2025-03-03
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-03-26
K · Immediate jeopardy
2024-12-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-01-21
E · Potential for more than minimal harm
2024-12-22
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 2025-01-21
E · Potential for more than minimal harm
2024-12-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-21
E · Potential for more than minimal harm
2024-12-22
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 2025-01-21
D · Potential for more than minimal harm
2024-12-22
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-01-21
E · Potential for more than minimal harm
2024-11-10
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 2024-12-03
E · Potential for more than minimal harm
2024-11-10
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 2024-12-03
E · Potential for more than minimal harm
2024-11-10
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 2024-12-03
E · Potential for more than minimal harm
2024-11-10
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-12-03
E · Potential for more than minimal harm
2024-11-10
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 2024-12-03
E · Potential for more than minimal harm
2024-11-10
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 2024-12-03
D · Potential for more than minimal harm
2024-11-10
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 2024-12-03
D · Potential for more than minimal harm
2024-11-10
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-10
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 2024-12-03
D · Potential for more than minimal harm
2024-11-10
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-10
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-10
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 2024-12-03
D · Potential for more than minimal harm
2024-11-10
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 2024-12-03
D · Potential for more than minimal harm
2024-11-10
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 2024-12-03
D · Potential for more than minimal harm
2024-11-10
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 2024-12-03
D · Potential for more than minimal harm
2024-11-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-10
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-10
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 2024-12-03
D · Potential for more than minimal harm
2024-11-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-10
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-05-22
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-06-15
D · Potential for more than minimal harm
2024-05-17
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 2024-06-15
F · Potential for more than minimal harm
2024-05-15
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-15
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 2024-06-12
D · Potential for more than minimal harm
2024-05-15
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-02-02
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-02
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-02
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 2024-03-01
D · Potential for more than minimal harm
2024-02-02
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 2024-03-01
D · Potential for more than minimal harm
2024-02-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-02
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 2024-03-01
E · Potential for more than minimal harm
2023-12-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-21
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-01-11
E · Potential for more than minimal harm
2023-10-16
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-11-11
E · Potential for more than minimal harm
2023-10-16
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 2023-11-11
E · Potential for more than minimal harm
2023-10-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-11
E · Potential for more than minimal harm
2023-10-16
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 2023-11-11
E · Potential for more than minimal harm
2023-10-16
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 2023-11-11
E · Potential for more than minimal harm
2023-10-16
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 2023-11-11
E · Potential for more than minimal harm
2023-10-16
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 2023-11-11
E · Potential for more than minimal harm
2023-10-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-16
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-16
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-16
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-16
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-16
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 2023-11-11
D · Potential for more than minimal harm
2023-10-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-16
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 2023-11-11
D · Potential for more than minimal harm
2023-10-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-10-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-11
D · Potential for more than minimal harm
2023-06-09
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 2023-07-08
D · Potential for more than minimal harm
2023-06-09
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 2023-07-08
E · Potential for more than minimal harm
2023-05-24
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 2023-06-22
D · Potential for more than minimal harm
2023-05-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-22
G · Actual harm
2023-05-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-08
E · Potential for more than minimal harm
2023-05-10
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 2023-06-08
D · Potential for more than minimal harm
2023-04-26
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 2023-05-19
D · Potential for more than minimal harm
2023-04-25
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 2023-05-19
D · Potential for more than minimal harm
2023-04-25
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 2023-05-19
Penalties and ownership
What sits behind the stars
$101,046
2024-12-22
Fine
Fine · fine $101,046
Fine
Ownership
Brady, Vern
5% Or Greater Indirect Ownership Interest · Individual
Case, Ryan
5% Or Greater Indirect Ownership Interest · Individual
Bradshaw, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Aspen Skilled Healthcare Inc
5% Or Greater Direct Ownership Interest · Organization
Bradshaw, Jeffrey
Corporate Officer · Individual
Bradshaw, Jeffrey
W-2 Managing Employee · Individual
Brady, Vern
Corporate Officer · Individual
Case, Ryan
Corporate Officer · Individual
Paxman, Marcus
Corporate Officer · Individual
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2-star overall rating with 2-star inspections with $55,450 in total fines with 15 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
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1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $144,692 in total fines with 52 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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