Cycle 1
Health 2025-05-02 · Fire 2025-05-02
13 health deficiencies
Top issue: Environmental (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Los Angeles, CA
Culver West Health Center
2-star overall rating with 3-star inspections with $117,037 in total fines with 13 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
4035 Grandview Blvd., Los Angeles, CA
(310) 390-9506
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
91
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.32
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.32
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.72
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,681
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.86% · Performance 24.27% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.03
Baseline 14.17% · Performance 8.18% · Measure score 6.03 · Achievement 0 · Improvement 6.03
Total nurse turnover
0
Baseline 61.29% · Performance 65.52% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.78
Baseline 3.68 hours · Performance 3.58 hours · Measure score 1.78 · Achievement 1.78 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.51% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 228 · Observed rate 12.72% · Lower 95% interval 7.81% |
| Discharge to community | 49.04% |
50.57%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 232 · Observed rate 36.64% · Lower 95% interval 41.42% |
| Medicare spending per beneficiary | 1.31 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 99.14% |
95.27%
3.9 pts better
|
Numerator 231 · Denominator 233 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 233 |
| Discharge self-care score | 44.94% |
53.69%
8.8 pts worse
|
Numerator 40 · Denominator 89 |
| Discharge mobility score | 56.18% |
50.94%
5.2 pts better
|
Numerator 50 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 0.43% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 233 · Adjusted rate 0.39% |
| Healthcare-associated infections requiring hospitalization | 8.18% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 205 · Observed rate 11.71% · Lower 95% interval 6.15% |
| Staff COVID-19 vaccination coverage | 9.57% |
8.2%
1.4 pts better
|
Numerator 9 · Denominator 94 |
| Staff flu vaccination coverage | 67.88% |
42%
25.9 pts better
|
Numerator 93 · Denominator 137 |
| Discharge function score | 42.7% |
56.45%
13.8 pts worse
|
Numerator 38 · Denominator 89 |
| Transfer of health information to provider | 92.55% |
95.95%
3.4 pts worse
|
Numerator 87 · Denominator 94 |
| Transfer of health information to patient | 90.36% |
96.28%
5.9 pts worse
|
Numerator 75 · Denominator 83 |
| Resident COVID-19 vaccinations up to date | 68.42% |
25.2%
43.2 pts better
|
Numerator 78 · Denominator 114 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.5 |
2.3
1.2 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 6.4 · Expected 3.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.8 · Expected 2.3 · 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 | 0.4% |
1.6%
1.2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.2% |
6.8%
5.4 pts worse
|
11.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 5.8% · Q3 19.0% · Q4 17.3% · 4Q avg 12.2% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
4.1%
3.3 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 11.5% · Q3 8.8% · Q4 1.8% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
13.7%
4.4 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 9.2% · Q3 10.9% · Q4 6.7% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.3% |
14.2%
3.9 pts better
|
16.7%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 17.9% · Q3 7.0% · Q4 5.7% · 4Q avg 10.3% · 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 | 17.2% |
11.0%
6.2 pts worse
|
16.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 4.8% · Q3 12.2% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
10.7%
0.7 pts worse
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 7.3% · Q3 11.1% · Q4 10.0% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
1.0%
1.7 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.8% · Q3 3.4% · Q4 3.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
1.2%
2.5 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 9.4% · Q4 5.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 1.7% |
10.9%
9.2 pts better
|
19.8%
18.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
4.7%
1 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 10.0% · Q3 5.8% · Q4 2.6% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
94.0%
5.7 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
11.2%
1.9 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 11.6% · Expected 14.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.0% |
1.5%
2.5 pts worse
|
1.6%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 7.9% · Q4 1.8% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.3% |
93.2%
2.1 pts better
|
79.7%
15.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
23.2%
5.3 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 37.9% · Expected 31.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-19 · Fire 2024-04-19
14 health deficiencies
Top issue: Resident Rights (5 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2021-10-28 · Fire 2021-10-28
31 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-02
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-05-29
E · Potential for more than minimal harm
2025-05-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-29
E · Potential for more than minimal harm
2025-05-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-29
E · Potential for more than minimal harm
2025-05-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-02
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-02
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-02
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-29
C · Minimal harm
2025-05-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-29
F · Potential for more than minimal harm
2024-04-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-19
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-19
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 2024-05-30
E · Potential for more than minimal harm
2024-04-19
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-19
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-19
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-04-19
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-05-30
C · Minimal harm
2024-04-19
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-05-30
C · Minimal harm
2024-04-19
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-05-30
C · Minimal harm
2024-04-19
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-05-30
F · Potential for more than minimal harm
2021-10-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-11-24
F · Potential for more than minimal harm
2021-10-28
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 2021-11-24
F · Potential for more than minimal harm
2021-10-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-24
E · Potential for more than minimal harm
2021-10-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-11-24
E · Potential for more than minimal harm
2021-10-28
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 2021-11-24
E · Potential for more than minimal harm
2021-10-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-24
E · Potential for more than minimal harm
2021-10-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-11-24
E · Potential for more than minimal harm
2021-10-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-11-24
D · Potential for more than minimal harm
2021-10-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-11-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2026-01-22
D · Potential for more than minimal harm
2025-05-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-02
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-25
D · Potential for more than minimal harm
2025-05-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-02
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 2025-05-23
D · Potential for more than minimal harm
2025-05-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-02
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 2025-05-20
D · Potential for more than minimal harm
2025-05-02
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 2025-05-23
D · Potential for more than minimal harm
2025-05-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-02
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-05-23
B · Minimal harm
2025-05-02
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 2025-05-23
D · Potential for more than minimal harm
2025-01-20
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-02-03
D · Potential for more than minimal harm
2024-09-18
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 2024-10-08
D · Potential for more than minimal harm
2024-07-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-05-07
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 2024-05-29
F · Potential for more than minimal harm
2024-04-19
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 2024-05-13
D · Potential for more than minimal harm
2024-04-19
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 2024-05-13
D · Potential for more than minimal harm
2024-04-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-19
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 2024-05-13
D · Potential for more than minimal harm
2024-04-19
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 2024-05-13
D · Potential for more than minimal harm
2024-04-19
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-19
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-05-13
B · Minimal harm
2024-04-19
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 2024-05-13
D · Potential for more than minimal harm
2024-03-15
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-01-29
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
2024-01-29
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 2024-02-08
D · Potential for more than minimal harm
2023-12-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-27
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 2024-01-11
D · Potential for more than minimal harm
2023-12-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-27
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 2024-01-11
E · Potential for more than minimal harm
2023-09-20
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 2023-10-18
J · Immediate jeopardy
2023-09-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-30
F · Potential for more than minimal harm
2023-09-15
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-09-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-09-15
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 2023-10-30
D · Potential for more than minimal harm
2023-09-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-09-15
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 2023-10-30
D · Potential for more than minimal harm
2023-03-24
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 2023-03-31
F · Potential for more than minimal harm
2021-10-28
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2021-12-01
E · Potential for more than minimal harm
2021-10-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-12-01
E · Potential for more than minimal harm
2021-10-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-01
E · Potential for more than minimal harm
2021-10-28
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2021-12-01
E · Potential for more than minimal harm
2021-10-28
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 2021-12-01
E · Potential for more than minimal harm
2021-10-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-12-01
E · Potential for more than minimal harm
2021-10-28
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 2021-12-01
D · Potential for more than minimal harm
2021-10-28
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 2021-12-01
D · Potential for more than minimal harm
2021-10-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-12-01
D · Potential for more than minimal harm
2021-10-28
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 2021-12-01
D · Potential for more than minimal harm
2021-10-28
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 2021-12-01
D · Potential for more than minimal harm
2021-10-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-12-01
D · Potential for more than minimal harm
2021-10-28
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 2021-12-01
D · Potential for more than minimal harm
2021-10-28
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 2021-12-01
D · Potential for more than minimal harm
2021-10-28
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-12-01
D · Potential for more than minimal harm
2021-10-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-12-01
D · Potential for more than minimal harm
2021-10-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-01
Penalties and ownership
What sits behind the stars
$117,037
2023-09-15
Fine
Fine · fine $117,037
Fine
Ownership
Culver West Health Center LLC
5% Or Greater Direct Ownership Interest · Organization
Jacobs, Harry
Corporate Officer · Individual
Maultasch, Ross
W-2 Managing Employee · Individual
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