Cycle 1
Health 2024-10-03 · Fire 2024-10-03
10 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Sacramento, CA
Double Tree Post Acute Care Center
2-star overall rating with 2-star inspections with abuse icon flag with $10,842 in total fines with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
7400 24th Street, Sacramento, CA
(916) 422-4825
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bvhc, LLC
Operator or chain grouping
Approved since
1977-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 4 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
0.75
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.74
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.68
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.34
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,659
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.24
Baseline 19.48% · Performance 19.93% · Measure score 3.24 · Achievement 3.24 · Improvement 0
Healthcare-associated infections
0
Baseline 6.27% · Performance 11.86% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.65
Baseline 4.26 hours · Performance 4.12 hours · Measure score 3.65 · Achievement 3.65 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.89% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 18.39% · Lower 95% interval 8.77% |
| Discharge to community | 32.19% |
50.57%
18.4 pts worse
|
Worse than the National Rate · Eligible stays 67 · Observed rate 19.4% · Lower 95% interval 22.55% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 103 · Denominator 103 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 103 |
| Discharge self-care score | 34.78% |
53.69%
18.9 pts worse
|
Numerator 24 · Denominator 69 |
| Discharge mobility score | 27.54% |
50.94%
23.4 pts worse
|
Numerator 19 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 1.94% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 103 · Adjusted rate 1.38% |
| Healthcare-associated infections requiring hospitalization | 11.86% |
7.12%
4.7 pts worse
|
Worse than the National Rate · Eligible stays 57 · Observed rate 24.56% · Lower 95% interval 7.16% |
| Staff COVID-19 vaccination coverage | 1.24% |
8.2%
7 pts worse
|
Numerator 3 · Denominator 241 |
| Staff flu vaccination coverage | 64.46% |
42%
22.5 pts better
|
Numerator 156 · Denominator 242 |
| Discharge function score | 31.88% |
56.45%
24.6 pts worse
|
Numerator 22 · Denominator 69 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 30% |
25.2%
4.8 pts better
|
Numerator 18 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.3
0.5 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
1.6
1.8 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.1 · Expected 1.5 · 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 | 0.5% |
1.6%
1.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · 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 | 2.3% |
4.1%
1.8 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 4.8% · Q4 2.2% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.8% |
13.7%
8.9 pts better
|
19.6%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.9% · Q3 5.7% · Q4 4.3% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
14.2%
0.1 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 11.5% · Q3 14.0% · Q4 14.8% · 4Q avg 14.1% · 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 | 7.7% |
11.0%
3.3 pts better
|
16.3%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 15.8% · Q3 0.0% · Q4 0.0% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.1% |
10.7%
6.6 pts better
|
14.9%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.8% · Q3 5.0% · Q4 2.4% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.0%
0.4 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
1.2%
3 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.5% · Q3 2.1% · Q4 5.2% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.7% |
10.9%
5.2 pts better
|
19.8%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 7.8% · Q3 4.8% · Q4 4.5% · 4Q avg 5.7% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.7%
1 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 4.3% · Q3 3.0% · Q4 1.6% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 27.3% |
11.2%
16.1 pts worse
|
12.0%
15.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.3% · Observed 29.0% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.2% |
93.2%
6 pts better
|
79.7%
19.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.8% |
23.2%
5.6 pts worse
|
23.9%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.8% · Observed 29.0% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-17 · Fire 2023-08-17
22 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2021-07-22 · Fire 2021-07-22
18 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-10-03
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-10-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-10-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-09
C · Minimal harm
2024-10-03
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-10-09
C · Minimal harm
2024-10-03
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-10-09
C · Minimal harm
2024-10-03
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-10-09
C · Minimal harm
2024-10-03
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-10-09
C · Minimal harm
2024-10-03
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-09
C · Minimal harm
2024-10-03
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-09
C · Minimal harm
2024-10-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-09
F · Potential for more than minimal harm
2023-08-17
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-12
E · Potential for more than minimal harm
2023-08-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-12
E · Potential for more than minimal harm
2023-08-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-12
E · Potential for more than minimal harm
2023-08-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-12
E · Potential for more than minimal harm
2023-08-17
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-09-12
E · Potential for more than minimal harm
2023-08-17
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 2023-09-12
E · Potential for more than minimal harm
2023-08-17
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-12
F · Potential for more than minimal harm
2021-07-22
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2021-09-14
D · Potential for more than minimal harm
2021-07-22
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-09-14
D · Potential for more than minimal harm
2021-07-22
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2021-09-14
D · Potential for more than minimal harm
2021-07-22
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-09-14
D · Potential for more than minimal harm
2021-07-22
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-09-14
D · Potential for more than minimal harm
2021-07-22
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2021-09-14
D · Potential for more than minimal harm
2021-07-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-14
D · Potential for more than minimal harm
2021-07-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-09-14
D · Potential for more than minimal harm
2021-07-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-09-14
D · Potential for more than minimal harm
2021-07-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-14
D · Potential for more than minimal harm
2021-07-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-09-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-22
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 2026-01-16
D · Potential for more than minimal harm
2025-07-09
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 2025-07-25
D · Potential for more than minimal harm
2025-07-09
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 2025-07-25
D · Potential for more than minimal harm
2024-10-24
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 2024-11-25
J · Immediate jeopardy
2024-10-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-10-03
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 2024-10-18
E · Potential for more than minimal harm
2024-10-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-10-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-10-03
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-10-03
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-10-03
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-04-17
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 2024-05-15
D · Potential for more than minimal harm
2023-12-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-28
F · Potential for more than minimal harm
2023-08-17
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-17
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 2023-09-08
E · Potential for more than minimal harm
2023-08-17
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 2023-09-08
E · Potential for more than minimal harm
2023-08-17
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 2023-09-08
E · Potential for more than minimal harm
2023-08-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-17
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 2023-09-08
E · Potential for more than minimal harm
2023-08-17
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-17
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-17
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 2023-09-08
E · Potential for more than minimal harm
2023-08-17
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-17
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-17
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 2023-09-08
D · Potential for more than minimal harm
2023-08-17
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 2023-09-08
D · Potential for more than minimal harm
2023-08-17
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 2023-09-08
D · Potential for more than minimal harm
2023-08-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-17
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
2023-08-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-17
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-17
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 2023-09-08
D · Potential for more than minimal harm
2023-07-18
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-06-15
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 2023-07-05
D · Potential for more than minimal harm
2023-04-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-04-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-21
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 2023-04-11
D · Potential for more than minimal harm
2023-03-09
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 2023-04-11
D · Potential for more than minimal harm
2023-03-07
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 2023-03-24
E · Potential for more than minimal harm
2021-07-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-08-31
E · Potential for more than minimal harm
2021-07-22
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2021-08-31
E · Potential for more than minimal harm
2021-07-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-07-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-07-22
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 2021-08-31
D · Potential for more than minimal harm
2021-07-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-07-22
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 2021-08-31
D · Potential for more than minimal harm
2021-07-22
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2021-08-31
B · Minimal harm
2021-07-22
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 2021-08-31
Penalties and ownership
What sits behind the stars
$10,842
2024-10-03
Fine
Fine · fine $10,842
Fine
Ownership
Bvhc, LLC
5% Or Greater Direct Ownership Interest · Organization
Boehrer, Bryan
5% Or Greater Indirect Ownership Interest · Individual
Martin, Richard
5% Or Greater Indirect Ownership Interest · Individual
Boehrer, Bryan
Operational/Managerial Control · Individual
Boehrer, Bryan
Corporate Officer · Individual
Martin, Richard
Operational/Managerial Control · Individual
Martin, Richard
Corporate Officer · Individual
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