Cycle 1
Health 2025-12-18 · Fire 2025-12-18
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Anaheim, CA
Buena Vista Care Center
3-star overall rating with 3-star inspections with 17 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
1440 S Euclid Avenue, Anaheim, CA
(714) 535-7264
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cambridge Healthcare Services
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
32 facilities
Chain averages 3 overall / 2 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
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.48
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.71
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,704
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9868
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.95
Baseline 19.76% · Performance 18.68% · Measure score 5.95 · Achievement 5.95 · Improvement 3.46
Healthcare-associated infections
0
Baseline 8.19% · Performance 15.52% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.79
Baseline 44.87% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 1.93
Adjusted total nurse staffing
1.05
Baseline 3.42 hours · Performance 3.38 hours · Measure score 1.05 · Achievement 1.05 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.03% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 155 · Observed rate 8.39% · Lower 95% interval 7.42% |
| Discharge to community | 50.38% |
50.57%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 90 · Observed rate 45.56% · Lower 95% interval 41.45% |
| Medicare spending per beneficiary | 1.6 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 99.44% |
95.27%
4.2 pts better
|
Numerator 179 · Denominator 180 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 180 |
| Discharge self-care score | 42.06% |
53.69%
11.6 pts worse
|
Numerator 53 · Denominator 126 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 42 · Denominator 126 |
| Pressure ulcers or injuries, new or worsened | 1.11% |
2.29%
1.2 pts better
|
Numerator 2 · Denominator 180 · Adjusted rate 0.79% |
| Healthcare-associated infections requiring hospitalization | 15.52% |
7.12%
8.4 pts worse
|
Worse than the National Rate · Eligible stays 146 · Observed rate 21.23% · Lower 95% interval 11.64% |
| Staff COVID-19 vaccination coverage | 2.38% |
8.2%
5.8 pts worse
|
Numerator 3 · Denominator 126 |
| Staff flu vaccination coverage | 20.74% |
42%
21.3 pts worse
|
Numerator 28 · Denominator 135 |
| Discharge function score | 45.24% |
56.45%
11.2 pts worse
|
Numerator 57 · Denominator 126 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | 97.37% |
96.28%
1.1 pts better
|
Numerator 37 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 51.14% |
25.2%
25.9 pts better
|
Numerator 45 · Denominator 88 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.0 |
2.3
1.7 pts worse
|
1.9
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 5.3 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.3 · 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 | 3.2% |
1.6%
1.6 pts worse
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.6% · Q3 5.2% · Q4 3.7% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 79.1% |
6.8%
72.3 pts worse
|
11.4%
67.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.2% · Q2 77.6% · Q3 77.8% · Q4 79.7% · 4Q avg 79.1% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
4.1%
3 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 9.2% · Q3 6.1% · Q4 12.1% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.5% |
13.7%
1.8 pts worse
|
19.6%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 16.9% · Q3 15.6% · Q4 12.2% · 4Q avg 15.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.8% |
14.2%
10.6 pts worse
|
16.7%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 26.4% · Q3 25.0% · Q4 20.7% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.6% |
11.0%
1.6 pts worse
|
16.3%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 18.0% · Q3 9.5% · Q4 8.3% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
10.7%
2.4 pts worse
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 14.9% · Q3 11.3% · Q4 12.3% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.0%
0.1 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.8% |
1.2%
3.6 pts worse
|
1.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.2% · Q3 4.5% · Q4 3.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.8% |
10.9%
0.1 pts better
|
19.8%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 9.4% · Q3 11.3% · Q4 6.8% · 4Q avg 10.8% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
4.7%
1.1 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.3% · Q3 7.0% · Q4 5.6% · 4Q avg 5.8% · 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 | 2.9% |
11.2%
8.3 pts better
|
12.0%
9.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.9% · Observed 3.2% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 4.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.5% |
93.2%
4.3 pts better
|
79.7%
17.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.1% |
23.2%
8.1 pts better
|
23.9%
8.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 13.9% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-01 · Fire 2024-11-01
30 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-02-14 · Fire 2023-02-14
21 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2026-01-15
F · Potential for more than minimal harm
2025-12-18
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
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 2026-01-15
E · Potential for more than minimal harm
2025-12-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2026-01-15
C · Minimal harm
2025-12-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-15
F · Potential for more than minimal harm
2024-11-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-11-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-11-01
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-11-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-11-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-18
C · Minimal harm
2024-11-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-18
E · Potential for more than minimal harm
2023-02-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-02-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-02-14
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-02-14
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-02-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-02-14
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 2023-02-27
D · Potential for more than minimal harm
2023-02-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-02-14
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-02-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-02-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-02-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-02-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-02-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-02-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-02-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-18
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 2026-01-15
E · Potential for more than minimal harm
2025-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-15
E · Potential for more than minimal harm
2025-12-18
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
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 2026-01-15
D · Potential for more than minimal harm
2025-12-18
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 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-18
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2026-01-15
B · Minimal harm
2025-12-18
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2026-01-15
B · Minimal harm
2025-12-18
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 2026-01-15
B · Minimal harm
2025-08-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Not marked corrected
D · Potential for more than minimal harm
2024-12-23
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-01-15
B · Minimal harm
2024-12-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-15
B · Minimal harm
2024-12-23
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 2025-01-15
F · Potential for more than minimal harm
2024-11-01
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 2024-12-01
E · Potential for more than minimal harm
2024-11-01
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-12-01
E · Potential for more than minimal harm
2024-11-01
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 2024-12-01
E · Potential for more than minimal harm
2024-11-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-01
E · Potential for more than minimal harm
2024-11-01
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-01
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 2024-12-01
D · Potential for more than minimal harm
2024-11-01
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-01
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 2024-12-01
D · Potential for more than minimal harm
2024-11-01
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-01
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 2024-12-01
D · Potential for more than minimal harm
2024-11-01
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-01
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 2024-12-01
D · Potential for more than minimal harm
2024-11-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-01
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 2024-12-01
D · Potential for more than minimal harm
2024-11-01
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-01
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-11-01
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 2024-12-01
D · Potential for more than minimal harm
2024-11-01
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-12-01
B · Minimal harm
2024-11-01
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-12-01
B · Minimal harm
2024-11-01
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 2024-12-01
B · Minimal harm
2024-11-01
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 2024-12-01
B · Minimal harm
2024-11-01
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-01
D · Potential for more than minimal harm
2023-11-15
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 2023-11-17
D · Potential for more than minimal harm
2023-10-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-02-14
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 2023-03-15
E · Potential for more than minimal harm
2023-02-14
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 2023-03-15
E · Potential for more than minimal harm
2023-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-14
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-14
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 2023-03-15
D · Potential for more than minimal harm
2023-02-14
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 2023-03-15
D · Potential for more than minimal harm
2023-02-14
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 2023-03-15
D · Potential for more than minimal harm
2023-02-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-14
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 2023-03-15
D · Potential for more than minimal harm
2023-02-14
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 2023-03-15
D · Potential for more than minimal harm
2023-02-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-14
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 2023-03-15
D · Potential for more than minimal harm
2023-02-14
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 2023-03-15
D · Potential for more than minimal harm
2023-02-14
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-14
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-03-15
B · Minimal harm
2023-02-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-15
B · Minimal harm
2023-02-14
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-03-15
Penalties and ownership
What sits behind the stars
Ownership
Win Win Enterprises, LLC
5% Or Greater Direct Ownership Interest · Organization
The Wintner Living Trust Dated 7/08/1992
5% Or Greater Indirect Ownership Interest · Organization
Smedra, Ira
5% Or Greater Direct Ownership Interest · Individual
Wintner, Jacob
5% Or Greater Indirect Ownership Interest · Individual
Shersher LP
5% Or Greater Direct Ownership Interest · Organization
Wolff Living Trust Dtd 03/09/2000
5% Or Greater Direct Ownership Interest · Organization
Sahebifard, Pegah
Operational/Managerial Control · Individual
Sahebifard, Pegah
W-2 Managing Employee · Individual
Smedra, Ira
Corporate Officer · Individual
Wintner, Jacob
Operational/Managerial Control · Individual
Wintner, Jacob
Corporate Officer · Individual
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4-star overall rating with 3-star inspections with 24 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Sun Mar Nursing Center
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5-star overall rating with 5-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Harbor Villa Care Center
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2-star overall rating with 1-star inspections with $8,824 in total fines with 36 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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