Cycle 1
Health 2025-05-30 · Fire 2025-05-30
10 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Norwalk, CA
Cottage Crest Post Acute
1-star overall rating with 1-star inspections with $69,390 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
12350 Rosecrans, Norwalk, CA
(562) 921-6624
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David & Frank Johnson
Operator or chain grouping
Approved since
1985-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
45 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.34
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.51
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.92
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
4.10
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,455
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 23.14% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 8.93% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.94
Baseline 56.45% · Performance 43.48% · Measure score 4.94 · Achievement 4.94 · Improvement 3.61
Adjusted total nurse staffing
3.19
Baseline 4.08 hours · Performance 3.99 hours · Measure score 3.19 · Achievement 3.19 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.13% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 18.97% · Lower 95% interval 8.18% |
| Discharge to community | 39.71% |
50.57%
10.9 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 22.5% · Lower 95% interval 27.24% |
| Medicare spending per beneficiary | 1.4 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 98.52% |
95.27%
3.2 pts better
|
Numerator 133 · Denominator 135 |
| Falls with major injury | 0.74% |
0.77%
About the same
|
Numerator 1 · Denominator 135 |
| Discharge self-care score | 44.44% |
53.69%
9.2 pts worse
|
Numerator 28 · Denominator 63 |
| Discharge mobility score | 47.62% |
50.94%
3.3 pts worse
|
Numerator 30 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 1.48% |
2.29%
0.8 pts better
|
Numerator 2 · Denominator 135 · Adjusted rate 1.09% |
| Healthcare-associated infections requiring hospitalization | 8.93% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 17.95% · Lower 95% interval 4.55% |
| Staff COVID-19 vaccination coverage | 24.53% |
8.2%
16.3 pts better
|
Numerator 26 · Denominator 106 |
| Staff flu vaccination coverage | 49.52% |
42%
7.5 pts better
|
Numerator 52 · Denominator 105 |
| Discharge function score | 50.79% |
56.45%
5.7 pts worse
|
Numerator 32 · Denominator 63 |
| Transfer of health information to provider | 97.22% |
95.95%
1.3 pts better
|
Numerator 70 · Denominator 72 |
| Transfer of health information to patient | 95% |
96.28%
1.3 pts worse
|
Numerator 19 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 17.33% |
25.2%
7.9 pts worse
|
Numerator 13 · Denominator 75 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.3
0.8 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 4.8 · Expected 2.9 · 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 1.4 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
98.5%
0.3 pts worse
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.5% · Q4 95.1% · 4Q avg 98.2% |
| 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 | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 11.4% |
6.8%
4.6 pts worse
|
11.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 13.5% · Q3 12.9% · Q4 11.4% · 4Q avg 11.4% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
4.1%
1.2 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 6.1% · Q3 0.0% · Q4 2.9% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
13.7%
2.3 pts worse
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 12.8% · Q3 17.9% · Q4 20.0% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.0% |
14.2%
11.2 pts better
|
16.7%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 0.0% · Q3 3.8% · Q4 0.0% · 4Q avg 3.0% · 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 | 5.1% |
11.0%
5.9 pts better
|
16.3%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
10.7%
1 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 8.8% · Q3 9.4% · Q4 6.1% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.0%
About the same
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
1.2%
0.8 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.6% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.4% |
10.9%
13.5 pts worse
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 22.6% · Q3 15.1% · Q4 33.7% · 4Q avg 24.4% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
4.7%
2.1 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 4.0% · Q3 9.7% · Q4 4.8% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
94.0%
1.8 pts worse
|
81.7%
10.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 86.4% · Q4 83.3% · 4Q avg 92.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
11.2%
0.1 pts worse
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 13.3% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 2.0% · Q4 1.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
93.2%
4.7 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.5% |
23.2%
8.3 pts worse
|
23.9%
7.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.5% · Observed 38.1% · Expected 28.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-11 · Fire 2024-06-11
23 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-29 · Fire 2023-06-29
31 health deficiencies
Top issue: Pharmacy Service (6 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-20
F · Potential for more than minimal harm
2024-06-11
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-11
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 2024-07-04
F · Potential for more than minimal harm
2024-06-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-04
E · Potential for more than minimal harm
2024-06-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-04
E · Potential for more than minimal harm
2024-06-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-04
E · Potential for more than minimal harm
2024-06-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-04
D · Potential for more than minimal harm
2024-06-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-04
C · Minimal harm
2024-06-11
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-07-04
D · Potential for more than minimal harm
2023-08-17
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-06-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-29
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-29
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 2023-07-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-30
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 2025-06-20
E · Potential for more than minimal harm
2025-05-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-30
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 2025-06-20
E · Potential for more than minimal harm
2025-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-30
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-30
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-30
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 2025-06-20
D · Potential for more than minimal harm
2025-05-30
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 2025-06-20
B · Minimal harm
2025-05-30
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 2025-06-20
D · Potential for more than minimal harm
2025-02-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-27
D · Potential for more than minimal harm
2024-12-10
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 2024-12-30
D · Potential for more than minimal harm
2024-10-11
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 2024-11-01
D · Potential for more than minimal harm
2024-10-11
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 2024-11-01
D · Potential for more than minimal harm
2024-10-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-01
K · Immediate jeopardy
2024-06-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-11
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 2024-07-08
F · Potential for more than minimal harm
2024-06-11
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-11
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 2024-07-08
F · Potential for more than minimal harm
2024-06-11
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 2024-07-08
F · Potential for more than minimal harm
2024-06-11
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-07-08
F · Potential for more than minimal harm
2024-06-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-11
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 2024-07-08
E · Potential for more than minimal harm
2024-06-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-11
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 2024-07-08
E · Potential for more than minimal harm
2024-06-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-06-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-08
D · Potential for more than minimal harm
2024-06-11
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-07-08
D · Potential for more than minimal harm
2024-06-11
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-07-08
D · Potential for more than minimal harm
2024-06-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-08
D · Potential for more than minimal harm
2024-06-11
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 2024-07-08
D · Potential for more than minimal harm
2024-06-11
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-08
B · Minimal harm
2024-06-11
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 2024-07-08
G · Actual harm
2024-01-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-09
G · Actual harm
2024-01-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-09
E · Potential for more than minimal harm
2024-01-09
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 2024-01-31
D · Potential for more than minimal harm
2023-12-15
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 2024-01-05
D · Potential for more than minimal harm
2023-11-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-10
J · Immediate jeopardy
2023-10-09
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 2023-11-01
D · Potential for more than minimal harm
2023-08-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-15
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 2023-09-08
D · Potential for more than minimal harm
2023-07-12
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 2023-08-12
D · Potential for more than minimal harm
2023-07-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-08-12
F · Potential for more than minimal harm
2023-06-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-07-29
F · Potential for more than minimal harm
2023-06-29
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 2023-07-29
F · Potential for more than minimal harm
2023-06-29
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-07-29
E · Potential for more than minimal harm
2023-06-29
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-07-29
E · Potential for more than minimal harm
2023-06-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-29
E · Potential for more than minimal harm
2023-06-29
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 2023-07-29
E · Potential for more than minimal harm
2023-06-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-29
E · Potential for more than minimal harm
2023-06-29
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 2023-07-29
E · Potential for more than minimal harm
2023-06-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-29
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 2023-07-29
D · Potential for more than minimal harm
2023-06-29
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-29
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-29
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-29
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 2023-07-29
C · Minimal harm
2023-06-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-07-29
B · Minimal harm
2023-06-29
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 2023-07-29
D · Potential for more than minimal harm
2023-04-18
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 2023-05-13
D · Potential for more than minimal harm
2023-03-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-04-14
Penalties and ownership
What sits behind the stars
$42,354
2024-06-11
Fine
Fine · fine $42,354
Fine
$16,445
2024-01-09
Fine
Fine · fine $16,445
Fine
$7,446
2023-10-09
Fine
Fine · fine $7,446
Fine
$3,145
2023-04-17
Fine
Fine · fine $3,145
Fine
Ownership
Johnson, Frank
5% Or Greater Indirect Ownership Interest · Individual
Dehghanmanesh, Adrian
Corporate Officer · Individual
Johnson, David
5% Or Greater Direct Ownership Interest · Individual
Johnson, Frank
5% Or Greater Direct Ownership Interest · Individual
Norwalk Post Acute LLC
5% Or Greater Direct Ownership Interest · Organization
Urbina, Christian
W-2 Managing Employee · Individual
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