Cycle 1
Health 2024-11-21 · Fire 2024-11-21
27 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Buena Park, CA
Buena Park Nursing Center
2-star overall rating with 2-star inspections with 27 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
8520 Western Avenue, Buena Park, CA
(714) 828-8222
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
143
Certified beds
Average residents
130
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Mandelbaum Family
Operator or chain grouping
Approved since
1977-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 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
0.70
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.78
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.94
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.42
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.48
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.90
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.98
CMS adjusted total nurse staffing hours
Case-mix index
1.86
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,630
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9891
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.80
Baseline 22.58% · Performance 19.64% · Measure score 4.80 · Achievement 3.87 · Improvement 4.80
Healthcare-associated infections
0
Baseline 9.35% · Performance 10.46% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.34
Baseline 37.70% · Performance 33.70% · Measure score 7.34 · Achievement 7.34 · Improvement 2.62
Adjusted total nurse staffing
2.06
Baseline 3.87 hours · Performance 3.66 hours · Measure score 2.06 · Achievement 2.06 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.8% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 239 · Observed rate 10.04% · Lower 95% interval 8.55% |
| Discharge to community | 38.68% |
50.57%
11.9 pts worse
|
Worse than the National Rate · Eligible stays 240 · Observed rate 30.42% · Lower 95% interval 32.42% |
| Medicare spending per beneficiary | 1.44 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 97.21% |
95.27%
1.9 pts better
|
Numerator 209 · Denominator 215 |
| Falls with major injury | 0.47% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 215 |
| Discharge self-care score | 70.09% |
53.69%
16.4 pts better
|
Numerator 75 · Denominator 107 |
| Discharge mobility score | 61.68% |
50.94%
10.7 pts better
|
Numerator 66 · Denominator 107 |
| Pressure ulcers or injuries, new or worsened | 4.65% |
2.29%
2.4 pts worse
|
Numerator 10 · Denominator 215 · Adjusted rate 2.86% |
| Healthcare-associated infections requiring hospitalization | 10.46% |
7.12%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 182 · Observed rate 13.19% · Lower 95% interval 7.11% |
| Staff COVID-19 vaccination coverage | 8.13% |
8.2%
0.1 pts worse
|
Numerator 17 · Denominator 209 |
| Staff flu vaccination coverage | 51.36% |
42%
9.4 pts better
|
Numerator 132 · Denominator 257 |
| Discharge function score | 68.22% |
56.45%
11.8 pts better
|
Numerator 73 · Denominator 107 |
| Transfer of health information to provider | 98.65% |
95.95%
2.7 pts better
|
Numerator 73 · Denominator 74 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 58 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 51.38% |
25.2%
26.2 pts better
|
Numerator 56 · Denominator 109 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.3
0.3 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 4.8 · Expected 3.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 1.9 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 1.7% · Q2 1.7% · Q3 0.9% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 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 who lose too much weight | 4.6% |
4.1%
0.5 pts worse
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.8% · Q3 2.9% · Q4 4.0% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
13.7%
4.2 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 7.5% · Q3 8.7% · Q4 10.6% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
14.2%
6.7 pts better
|
16.7%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 6.5% · Q3 5.1% · Q4 8.8% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.2% |
0.4%
0.2 pts better
|
0.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.2% |
11.0%
1.2 pts worse
|
16.3%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.5% |
10.7%
4.8 pts worse
|
14.9%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 13.0% · Q3 12.5% · Q4 6.2% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.3% |
1.0%
2.3 pts worse
|
1.0%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.6% · Q3 1.9% · Q4 2.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.2%
0.1 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.1% |
10.9%
0.2 pts worse
|
19.8%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 20.6% · Q3 7.8% · Q4 7.7% · 4Q avg 11.1% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
4.7%
2.5 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 7.7% · Q3 7.7% · Q4 5.5% · 4Q avg 7.2% · 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 | 4.6% |
11.2%
6.6 pts better
|
12.0%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 5.1% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.5% |
1.5%
2 pts worse
|
1.6%
1.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 4.7% · Q3 2.0% · Q4 1.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.9% |
23.2%
4.3 pts better
|
23.9%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 20.2% · Expected 25.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-28 · Fire 2022-06-28
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-09-30 · Fire 2019-09-30
15 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-21
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-21
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
2024-11-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-21
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-12-03
E · Potential for more than minimal harm
2022-06-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-06-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-28
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-15
D · Potential for more than minimal harm
2019-09-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-11-04
D · Potential for more than minimal harm
2019-09-30
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 2019-11-04
D · Potential for more than minimal harm
2019-09-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-04
D · Potential for more than minimal harm
2019-09-30
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-11-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-30
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-30
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.
Not marked corrected
D · Potential for more than minimal harm
2025-11-03
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 2025-11-20
D · Potential for more than minimal harm
2025-11-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-20
B · Minimal harm
2025-11-03
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-11-20
D · Potential for more than minimal harm
2025-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-20
G · Actual harm
2025-10-30
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 2025-12-11
D · Potential for more than minimal harm
2024-11-21
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 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
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 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
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 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
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 2024-12-20
D · Potential for more than minimal harm
2024-11-21
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 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
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 2024-12-20
D · Potential for more than minimal harm
2024-11-21
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 2024-12-20
D · Potential for more than minimal harm
2024-11-21
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 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
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 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-12-20
B · Minimal harm
2024-11-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-20
B · Minimal harm
2024-11-21
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 2024-12-20
D · Potential for more than minimal harm
2024-08-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-02
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 2024-08-01
B · Minimal harm
2024-07-02
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 2024-08-01
D · Potential for more than minimal harm
2024-05-30
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 2024-06-28
D · Potential for more than minimal harm
2024-05-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-28
D · Potential for more than minimal harm
2023-12-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-19
B · Minimal harm
2023-11-29
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-12-31
E · Potential for more than minimal harm
2022-06-28
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 2022-07-27
D · Potential for more than minimal harm
2022-06-28
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-07-27
D · Potential for more than minimal harm
2022-06-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-07-27
D · Potential for more than minimal harm
2022-06-28
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 2022-07-27
D · Potential for more than minimal harm
2022-06-28
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 2022-07-27
D · Potential for more than minimal harm
2022-06-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-27
D · Potential for more than minimal harm
2022-06-28
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 2022-07-27
D · Potential for more than minimal harm
2022-06-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-27
D · Potential for more than minimal harm
2022-06-28
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 2022-07-27
D · Potential for more than minimal harm
2022-06-28
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 2022-07-27
E · Potential for more than minimal harm
2019-09-30
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 2019-10-30
D · Potential for more than minimal harm
2019-09-30
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 2019-10-30
D · Potential for more than minimal harm
2019-09-30
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 2019-10-30
D · Potential for more than minimal harm
2019-09-30
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 2019-10-30
D · Potential for more than minimal harm
2019-09-30
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 2019-10-30
D · Potential for more than minimal harm
2019-09-30
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 2019-10-30
D · Potential for more than minimal harm
2019-09-30
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2019-10-30
D · Potential for more than minimal harm
2019-09-30
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 2019-10-30
D · Potential for more than minimal harm
2019-09-30
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-10-30
D · Potential for more than minimal harm
2019-09-30
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2019-10-30
D · Potential for more than minimal harm
2019-09-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-30
B · Minimal harm
2019-09-30
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 2019-10-30
B · Minimal harm
2019-09-30
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 2019-10-30
Penalties and ownership
What sits behind the stars
$0
2025-10-30
Payment Denial
Payment Denial · denial start 2025-11-28 · 13 days
13 day denial
Ownership
The Bentzion Mandelbaum 2021 Irrevocable Gift Trust No. 2
5% Or Greater Direct Ownership Interest · Organization
The Simcha Mandelbaum 2021 Irrevocable Gift Trust No. 2
5% Or Greater Direct Ownership Interest · Organization
The Janet Mandelbaum 2021 Irrevocable Gift Trust No 2
5% Or Greater Direct Ownership Interest · Organization
Castro-Garcia, Maria
Operational/Managerial Control · Individual
Castro-Garcia, Maria
Corporate Officer · Individual
Jacinto, Jocelyn
Operational/Managerial Control · Individual
Maldonado, Jose
Operational/Managerial Control · Individual
Mandelbaum, Janet
Operational/Managerial Control · Individual
Mandelbaum, Janet
Corporate Director · Individual
Mandelbaum, Janet
Corporate Officer · Individual
Moyo, Maricor
Operational/Managerial Control · Individual
Navarro, Frencita
Operational/Managerial Control · Individual
Pham, Julie
Operational/Managerial Control · Individual
Pham, Julie
Corporate Officer · Individual
Rama, Vann
Operational/Managerial Control · Individual
Roberts, Crystal
Operational/Managerial Control · Individual
Shams, Fariborz
Operational/Managerial Control · Individual
Um, Jenny
Operational/Managerial Control · Individual
Williams, Clinton
Operational/Managerial Control · Individual
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