Duarte, CA

Community Care Center

3-star overall rating with 2-star inspections with abuse icon flag with 15 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

2335 S. Mountain Ave, Duarte, CA

(626) 357-3207

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

145

Certified beds

Average residents

144

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1974-03-31

CMS approved date

Coverage

Medicaid

Participation flags

Changed ownership

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

0.23

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

0.67

Licensed practical nurse staffing · state 1.22 · national 0.87

Aide hours / resident day

1.88

Nurse aide staffing · state 2.64 · national 2.35

Total nurse hours

2.78

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

0.90

RN + LPN hours · state 1.87 · national 1.54

Weekend hours

2.47

Weekend nurse staffing · state 4.08 · national 3.43

Weekend RN hours

0.18

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.33

CMS adjusted RN staffing hours

Adjusted total hours

4.07

CMS adjusted total nurse staffing hours

Case-mix index

0.93

Higher values indicate more complex resident acuity

RN turnover

17%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

25%

Annual nurse turnover · state 38% · national 46%

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Medicare spending per beneficiary	Not Available	1.02	This provider is not required to submit SNF QRP data.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Staff COVID-19 vaccination coverage	Not Available	8.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.9	2.3 1.4 pts better	1.9 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.6	1.6 1 pts better	1.8 1.2 pts better	Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.4 · 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	1.0%	1.6% 0.6 pts better	3.3% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 1.4% · Q4 1.4% · 4Q avg 1.0% · 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	2.2%	4.1% 1.9 pts better	5.4% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.4% · Q3 2.1% · Q4 2.1% · 4Q avg 2.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	18.8%	13.7% 5.1 pts worse	19.6% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 18.6% · Q3 19.4% · Q4 19.4% · 4Q avg 18.8%
Percentage of long-stay residents who received an antipsychotic medication	97.3%	14.2% 83.1 pts worse	16.7% 80.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q4 100.0% · 4Q avg 97.3% · 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	0.3%	11.0% 10.7 pts better	16.3% 16 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	0.5%	10.7% 10.2 pts better	14.9% 14.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	0.7%	10.9% 10.2 pts better	19.8% 19.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 1.1% · Q4 0.5% · 4Q avg 0.7%
Percentage of long-stay residents with pressure ulcers	0.0%	4.7% 4.7 pts better	5.1% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · 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 · 4Q avg 100.0%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-24 · Fire 2025-07-24

15 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-06-28 · Fire 2024-06-28

36 health deficiencies

Top issue: Quality of Life and Care (9 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2022-04-08 · Fire 2022-04-08

21 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (7 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-07-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-08-22

E · Potential for more than minimal harm 2025-07-24

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-08-22

E · Potential for more than minimal harm 2025-07-24

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-07-24

K162 · Construction Deficiencies

Fire Safety

Have a combustible roofing system that meets safety standards.

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-07-24

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-07-24

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-07-24

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-07-24

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-07-24

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-08-22

F · Potential for more than minimal harm 2024-06-28

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-07-24

F · Potential for more than minimal harm 2024-06-28

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2024-07-24

F · Potential for more than minimal harm 2024-06-28

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-07-24

E · Potential for more than minimal harm 2024-06-28

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-07-24

E · Potential for more than minimal harm 2024-06-28

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-06-28

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-06-28

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-07-24

E · Potential for more than minimal harm 2023-03-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-03-30

F · Potential for more than minimal harm 2022-04-08

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2022-04-25

F · Potential for more than minimal harm 2022-04-08

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-04-25

E · Potential for more than minimal harm 2022-04-08

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 2022-04-25

E · Potential for more than minimal harm 2022-04-08

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2022-04-25

E · Potential for more than minimal harm 2022-04-08

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-04-25

E · Potential for more than minimal harm 2022-04-08

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-04-25

E · Potential for more than minimal harm 2022-04-08

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-04-25

E · Potential for more than minimal harm 2022-04-08

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-04-25

D · Potential for more than minimal harm 2022-04-08

K111 · Construction Deficiencies

Fire Safety

Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

Corrected 2022-04-25

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-12

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 2025-10-03

D · Potential for more than minimal harm 2025-07-29

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2025-08-22

E · Potential for more than minimal harm 2025-07-24

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-08-15

E · Potential for more than minimal harm 2025-07-24

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 2025-08-15

E · Potential for more than minimal harm 2025-07-24

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 2025-08-15

E · Potential for more than minimal harm 2025-07-24

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 2025-08-15

D · Potential for more than minimal harm 2025-07-24

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 2025-08-15

D · Potential for more than minimal harm 2025-07-24

F627 · Resident Rights Deficiencies

Health

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Corrected 2025-08-15

D · Potential for more than minimal harm 2025-07-24

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 2025-08-15

D · Potential for more than minimal harm 2025-07-24

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-08-15

D · Potential for more than minimal harm 2025-07-24

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-08-15

B · Minimal harm 2025-07-24

F912 · Environmental Deficiencies

Health

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Corrected 2025-08-15

D · Potential for more than minimal harm 2025-06-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-07-14

D · Potential for more than minimal harm 2025-04-01

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 2025-04-23

D · Potential for more than minimal harm 2025-03-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-25

E · Potential for more than minimal harm 2025-02-04

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2025-02-27

D · Potential for more than minimal harm 2025-02-04

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 2025-02-27

D · Potential for more than minimal harm 2025-01-23

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 2025-02-14

E · Potential for more than minimal harm 2024-12-30

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 2025-01-22

E · Potential for more than minimal harm 2024-12-20

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 2025-01-17

E · Potential for more than minimal harm 2024-12-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-01-17

E · Potential for more than minimal harm 2024-12-20

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-01-17

D · Potential for more than minimal harm 2024-11-20

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 2024-12-13

D · Potential for more than minimal harm 2024-11-13

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 2024-12-05

D · Potential for more than minimal harm 2024-11-13

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 2024-12-05

D · Potential for more than minimal harm 2024-11-13

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2024-12-05

D · Potential for more than minimal harm 2024-10-29

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 2024-11-13

D · Potential for more than minimal harm 2024-10-17

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 2024-11-04

D · Potential for more than minimal harm 2024-10-17

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-11-04

D · Potential for more than minimal harm 2024-10-09

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-10-31

D · Potential for more than minimal harm 2024-09-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-20

D · Potential for more than minimal harm 2024-08-12

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 2024-09-03

D · Potential for more than minimal harm 2024-08-12

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 2024-09-03

D · Potential for more than minimal harm 2024-08-12

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 2024-09-03

D · Potential for more than minimal harm 2024-08-08

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 2024-08-23

D · Potential for more than minimal harm 2024-07-09

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 2024-07-29

E · Potential for more than minimal harm 2024-06-28

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 2024-07-24

E · Potential for more than minimal harm 2024-06-28

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 2024-07-24

E · Potential for more than minimal harm 2024-06-28

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-07-24

E · Potential for more than minimal harm 2024-06-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-07-24

E · Potential for more than minimal harm 2024-06-28

F909 · Environmental Deficiencies

Health

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Corrected 2024-07-24

E · Potential for more than minimal harm 2024-06-28

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-07-24

E · Potential for more than minimal harm 2024-06-28

F926 · Environmental Deficiencies

Health

Have policies on smoking.

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-06-28

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 2024-07-24

D · Potential for more than minimal harm 2024-06-28

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 2024-07-24

D · Potential for more than minimal harm 2024-06-28

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-06-28

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-06-28

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-07-24

D · Potential for more than minimal harm 2024-06-18

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 2024-07-03

D · Potential for more than minimal harm 2024-05-01

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 2024-05-01

G · Actual harm 2024-03-20

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2024-04-23

D · Potential for more than minimal harm 2024-02-13

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 2024-03-05

D · Potential for more than minimal harm 2024-01-12

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-02-08

D · Potential for more than minimal harm 2024-01-12

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 2024-02-08

D · Potential for more than minimal harm 2024-01-12

F776 · Administration Deficiencies

Health

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Corrected 2024-02-08

D · Potential for more than minimal harm 2023-10-30

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2023-11-25

E · Potential for more than minimal harm 2023-09-21

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 2023-10-13

D · Potential for more than minimal harm 2023-09-09

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2023-10-06

D · Potential for more than minimal harm 2023-09-07

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 2023-09-28

E · Potential for more than minimal harm 2023-08-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-08-30

D · Potential for more than minimal harm 2023-08-03

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 2023-08-24

J · Immediate jeopardy 2023-06-05

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 2023-07-03

D · Potential for more than minimal harm 2023-06-05

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2023-07-03

G · Actual harm 2023-04-18

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 2023-05-08

F · Potential for more than minimal harm 2022-04-08

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 2022-04-30

D · Potential for more than minimal harm 2022-04-08

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2022-04-30

D · Potential for more than minimal harm 2022-04-08

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 2022-04-30

D · Potential for more than minimal harm 2022-04-08

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 2022-04-30

D · Potential for more than minimal harm 2022-04-08

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-04-30

D · Potential for more than minimal harm 2022-04-08

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 2022-04-30

D · Potential for more than minimal harm 2022-04-08

F758 · Pharmacy Service Deficiencies

Health

Corrected 2022-04-30

D · Potential for more than minimal harm 2022-04-08

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 2022-04-30

Penalties and ownership