Cycle 1
Health 2025-02-27 · Fire 2025-02-27
12 health deficiencies
Top issue: Resident Rights (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Sacramento, CA
Bruceville Terrace - D/P SNF Of Methodist Hospital
5-star overall rating with 4-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
8151 Bruceville Road, Sacramento, CA
(916) 423-6000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
171
Certified beds
Average residents
163
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Commonspirit Health
Operator or chain grouping
Approved since
1989-03-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.75
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.76
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.13
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.37
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.63
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
1.33
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.79
CMS adjusted RN staffing hours
Adjusted total hours
5.24
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
20%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
853
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.98
Composite VBP score used to determine payment impact.
Payment multiplier
1.0178
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.65
Baseline 21.47% · Performance 19.28% · Measure score 4.65 · Achievement 4.65 · Improvement 4.44
Healthcare-associated infections
4.97
Baseline 6.68% · Performance 6.35% · Measure score 4.97 · Achievement 4.97 · Improvement 1.45
Total nurse turnover
10
Performance 22.28% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.57
Baseline 4.42 hours · Performance 4.66 hours · Measure score 5.57 · Achievement 5.57 · Improvement 1.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.89% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 352 · Observed rate 14.49% · Lower 95% interval 9.41% |
| Discharge to community | 61.81% |
50.57%
11.2 pts better
|
Better than the National Rate · Eligible stays 352 · Observed rate 54.83% · Lower 95% interval 55.6% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 61.75% |
95.27%
33.5 pts worse
|
Numerator 134 · Denominator 217 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 217 |
| Discharge self-care score | 76.51% |
53.69%
22.8 pts better
|
Numerator 114 · Denominator 149 |
| Discharge mobility score | 67.79% |
50.94%
16.9 pts better
|
Numerator 101 · Denominator 149 |
| Pressure ulcers or injuries, new or worsened | 5.07% |
2.29%
2.8 pts worse
|
Numerator 11 · Denominator 217 · Adjusted rate 5.04% |
| Healthcare-associated infections requiring hospitalization | 6.35% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 192 · Observed rate 5.73% · Lower 95% interval 4.07% |
| Staff COVID-19 vaccination coverage | 3.63% |
8.2%
4.6 pts worse
|
Numerator 7 · Denominator 193 |
| Staff flu vaccination coverage | 69.31% |
42%
27.3 pts better
|
Numerator 140 · Denominator 202 |
| Discharge function score | 77.85% |
56.45%
21.4 pts better
|
Numerator 116 · Denominator 149 |
| Transfer of health information to provider | 99.05% |
95.95%
3.1 pts better
|
Numerator 104 · Denominator 105 |
| Transfer of health information to patient | 97.59% |
96.28%
1.3 pts better
|
Numerator 81 · Denominator 83 |
| Resident COVID-19 vaccinations up to date | 37.61% |
25.2%
12.4 pts better
|
Numerator 44 · Denominator 117 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
98.5%
1.8 pts worse
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 95.0% · Q3 96.6% · Q4 99.1% · 4Q avg 96.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
1.6%
0.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 0.0% · Q4 2.8% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
6.8%
6.5 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
4.1%
2 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 2.7% · Q3 7.2% · Q4 7.0% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.1% |
13.7%
3.6 pts better
|
19.6%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.9% · Q3 9.7% · Q4 9.8% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
14.2%
3 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 7.8% · Q3 12.3% · Q4 12.5% · 4Q avg 11.2% · 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 | 16.5% |
11.0%
5.5 pts worse
|
16.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 15.6% · Q3 22.4% · Q4 9.1% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.5% |
10.7%
1.8 pts worse
|
14.9%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 13.1% · Q3 12.4% · Q4 11.0% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
1.0%
0.9 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.5% · Q3 1.7% · Q4 1.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 1.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.2% |
10.9%
1.7 pts better
|
19.8%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 11.2% · Q3 7.3% · Q4 9.4% · 4Q avg 9.2% |
| Percentage of long-stay residents with pressure ulcers | 12.4% |
4.7%
7.7 pts worse
|
5.1%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 15.1% · Q3 13.4% · Q4 11.1% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
94.0%
0.4 pts worse
|
81.7%
11.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 96.1% · Q3 92.1% · Q4 90.6% · 4Q avg 93.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.7% |
11.2%
4.5 pts worse
|
12.0%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 15.6% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 1.4% · Q4 0.8% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
93.2%
3.2 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.7% |
23.2%
3.5 pts better
|
23.9%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 19.6% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
13 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-02-09 · Fire 2023-02-09
19 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-02-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-27
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2025-03-13
D · Potential for more than minimal harm
2024-02-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-02-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-02-09
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 2024-02-26
D · Potential for more than minimal harm
2024-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-02-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-02-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-02-09
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-02-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-26
F · Potential for more than minimal harm
2023-02-09
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-02-14
E · Potential for more than minimal harm
2023-02-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-14
E · Potential for more than minimal harm
2023-02-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-02-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-02-09
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-02-14
C · Minimal harm
2023-02-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-19
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 2026-01-15
D · Potential for more than minimal harm
2025-07-30
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-08-19
D · Potential for more than minimal harm
2025-07-22
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 2025-08-05
D · Potential for more than minimal harm
2025-07-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-07-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-07-08
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 2025-07-24
E · Potential for more than minimal harm
2025-02-27
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-03-20
E · Potential for more than minimal harm
2025-02-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-20
E · Potential for more than minimal harm
2025-02-27
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 2025-03-20
D · Potential for more than minimal harm
2025-02-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-27
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-03-20
D · Potential for more than minimal harm
2024-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-07-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-30
E · Potential for more than minimal harm
2024-02-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-03
E · Potential for more than minimal harm
2024-02-09
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 2024-03-03
E · Potential for more than minimal harm
2024-02-09
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 2024-03-03
E · Potential for more than minimal harm
2024-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-03
D · Potential for more than minimal harm
2024-02-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-03
D · Potential for more than minimal harm
2024-02-09
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 2024-03-03
D · Potential for more than minimal harm
2024-02-09
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 2024-03-03
D · Potential for more than minimal harm
2024-02-09
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 2024-03-03
D · Potential for more than minimal harm
2024-02-09
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 2024-03-03
D · Potential for more than minimal harm
2024-02-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-03
D · Potential for more than minimal harm
2023-07-05
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-05-12
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 2023-06-12
D · Potential for more than minimal harm
2023-03-24
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 2023-03-30
F · Potential for more than minimal harm
2023-02-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-03-03
E · Potential for more than minimal harm
2023-02-09
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 2023-03-03
E · Potential for more than minimal harm
2023-02-09
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 2023-03-03
E · Potential for more than minimal harm
2023-02-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-03
E · Potential for more than minimal harm
2023-02-09
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 2023-03-03
E · Potential for more than minimal harm
2023-02-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-09
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 2023-03-03
D · Potential for more than minimal harm
2023-02-09
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 2023-03-03
D · Potential for more than minimal harm
2023-02-09
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 2023-03-03
D · Potential for more than minimal harm
2023-02-09
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 2023-03-03
D · Potential for more than minimal harm
2023-02-09
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 2023-03-03
D · Potential for more than minimal harm
2023-02-09
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 2023-03-03
D · Potential for more than minimal harm
2023-02-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-09
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 2023-03-03
D · Potential for more than minimal harm
2023-02-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-09
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 2023-03-03
Penalties and ownership
What sits behind the stars
Ownership
Commonspirit Health
5% Or Greater Indirect Ownership Interest · Organization
Dignity Community Care
5% Or Greater Direct Ownership Interest · Organization
Carswell, Scott
Corporate Director · Individual
Commonspirit Health
Operational/Managerial Control · Organization
Dignity Community Care
Operational/Managerial Control · Organization
Melfi, Mitch
Corporate Director · Individual
Melfi, Mitch
Corporate Officer · Individual
Morissette, Daniel
Corporate Officer · Individual
O'quinn, Marvin
Corporate Director · Individual
O'quinn, Marvin
Corporate Officer · Individual
Petersdorf, John
Operational/Managerial Control · Individual
Petersdorf, John
Corporate Officer · Individual
Petersdorf, John
W-2 Managing Employee · Individual
Scharmann, Steven
Operational/Managerial Control · Individual
Scharmann, Steven
Corporate Officer · Individual
Scharmann, Steven
W-2 Managing Employee · Individual
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