Cycle 1
Health 2025-03-27 · Fire 2025-03-27
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Downey, CA
Downey Post Acute
4-star overall rating with 3-star inspections with $13,575 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
13007 S. Paramount Blvd., Downey, CA
(562) 923-9301
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1977-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.31
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.30
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.86
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,325
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.66
Baseline 20.36% · Performance 20.66% · Measure score 1.66 · Achievement 1.66 · Improvement 0
Healthcare-associated infections
0
Baseline 7.70% · Performance 8.35% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.29
Baseline 55.32% · Performance 46.15% · Measure score 4.29 · Achievement 4.29 · Improvement 2.51
Adjusted total nurse staffing
2.36
Baseline 3.93 hours · Performance 3.75 hours · Measure score 2.36 · Achievement 2.36 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.47% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 244 · Observed rate 14.75% · Lower 95% interval 10.11% |
| Discharge to community | 44.81% |
50.57%
5.8 pts worse
|
No Different than the National Rate · Eligible stays 205 · Observed rate 37.56% · Lower 95% interval 36.46% |
| Medicare spending per beneficiary | 1.38 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 99.32% |
95.27%
4 pts better
|
Numerator 146 · Denominator 147 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 147 |
| Discharge self-care score | 40.58% |
53.69%
13.1 pts worse
|
Numerator 28 · Denominator 69 |
| Discharge mobility score | 52.17% |
50.94%
1.2 pts better
|
Numerator 36 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 147 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.35% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 133 · Observed rate 9.77% · Lower 95% interval 5.64% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 164 |
| Staff flu vaccination coverage | 31.79% |
42%
10.2 pts worse
|
Numerator 55 · Denominator 173 |
| Discharge function score | 57.97% |
56.45%
1.5 pts better
|
Numerator 40 · Denominator 69 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 56 · Denominator 56 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 29.41% |
25.2%
4.2 pts better
|
Numerator 20 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.3
0.2 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 4.3 · Expected 3.2 · 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 0.9 · 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 | 94.6% |
98.2%
3.6 pts worse
|
95.5%
0.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
1.6%
About the same
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 0.0% · Q4 3.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 76.1% |
6.8%
69.3 pts worse
|
11.4%
64.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 67.9% · Q2 65.5% · Q3 81.5% · Q4 90.6% · 4Q avg 76.1% |
| Percentage of long-stay residents who lose too much weight | 0.5% |
4.1%
3.6 pts better
|
5.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.8% |
13.7%
4.9 pts better
|
19.6%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 7.9% · Q3 11.7% · Q4 9.7% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
14.2%
9 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.6% · Q3 7.9% · Q4 4.9% · 4Q avg 5.2% · 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 | 8.6% |
11.0%
2.4 pts better
|
16.3%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 8.6% · Q3 4.1% · Q4 16.4% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.3% |
10.7%
8.6 pts worse
|
14.9%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 17.0% · Q3 19.2% · Q4 27.3% · 4Q avg 19.3% · 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 | 10.9% |
10.9%
About the same
|
19.8%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 3.9% · Q3 16.4% · Q4 15.2% · 4Q avg 10.9% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
4.7%
1.4 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 8.1% · Q3 4.4% · Q4 4.0% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
94.0%
5.8 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.8% |
11.2%
7.4 pts better
|
12.0%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.8% · Observed 4.7% · Expected 13.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.7% · Q4 0.7% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
93.2%
1.8 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
23.2%
5.3 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 20.9% · Expected 27.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
25 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2021-06-04 · Fire 2021-06-04
22 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-03-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-26
D · Potential for more than minimal harm
2024-03-21
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 2024-03-28
E · Potential for more than minimal harm
2021-06-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-07-13
D · Potential for more than minimal harm
2021-06-04
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2021-07-13
D · Potential for more than minimal harm
2021-06-04
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2021-07-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-26
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 2025-12-17
D · Potential for more than minimal harm
2025-11-18
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 2025-11-21
D · Potential for more than minimal harm
2025-07-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-07
D · Potential for more than minimal harm
2025-07-24
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 2025-08-07
E · Potential for more than minimal harm
2025-03-27
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 2025-04-20
E · Potential for more than minimal harm
2025-03-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-27
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-27
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 2025-04-20
D · Potential for more than minimal harm
2025-03-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-20
B · Minimal harm
2025-03-27
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 2025-04-20
D · Potential for more than minimal harm
2025-03-24
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 2025-04-04
D · Potential for more than minimal harm
2025-03-24
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 2025-04-04
D · Potential for more than minimal harm
2024-10-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-09-13
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2024-09-24
G · Actual harm
2024-08-13
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 2024-08-30
D · Potential for more than minimal harm
2024-08-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-08-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-06-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-05-15
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-05-07
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 2024-05-20
F · Potential for more than minimal harm
2024-03-21
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 2024-04-12
D · Potential for more than minimal harm
2024-03-21
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 2024-04-12
D · Potential for more than minimal harm
2024-03-21
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 2024-04-12
D · Potential for more than minimal harm
2024-03-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-21
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-21
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-21
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-21
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 2024-04-12
D · Potential for more than minimal harm
2024-03-21
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 2024-04-12
D · Potential for more than minimal harm
2024-03-21
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 2024-04-12
D · Potential for more than minimal harm
2024-03-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-21
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-21
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 2024-04-12
D · Potential for more than minimal harm
2024-01-24
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 2024-02-16
E · Potential for more than minimal harm
2023-12-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-09-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-08-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-09
D · Potential for more than minimal harm
2023-06-15
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 2023-07-15
D · Potential for more than minimal harm
2023-03-22
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 2023-04-01
D · Potential for more than minimal harm
2023-03-22
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 2023-04-01
E · Potential for more than minimal harm
2021-06-04
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 2021-07-20
E · Potential for more than minimal harm
2021-06-04
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 2021-07-20
E · Potential for more than minimal harm
2021-06-04
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-07-20
E · Potential for more than minimal harm
2021-06-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-20
D · Potential for more than minimal harm
2021-06-04
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2021-07-20
D · Potential for more than minimal harm
2021-06-04
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2021-07-20
D · Potential for more than minimal harm
2021-06-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-07-20
D · Potential for more than minimal harm
2021-06-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-07-20
D · Potential for more than minimal harm
2021-06-04
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 2021-07-20
D · Potential for more than minimal harm
2021-06-04
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-07-20
D · Potential for more than minimal harm
2021-06-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-07-20
D · Potential for more than minimal harm
2021-06-04
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2021-07-20
D · Potential for more than minimal harm
2021-06-04
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 2021-07-20
D · Potential for more than minimal harm
2021-06-04
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 2021-07-20
D · Potential for more than minimal harm
2021-06-04
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2021-07-20
Penalties and ownership
What sits behind the stars
$13,575
2024-08-09
Fine
Fine · fine $13,575
Fine
Ownership
Flagstone Healthcare South LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Chadha, Arinder
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Kim, Jesse
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Twomagnets LLC
Operational/Managerial Control · Organization
Williams, Wilestela
Operational/Managerial Control · Individual
Willits, Adam
Corporate Director · Individual
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