Cycle 1
Health 2024-01-12 · Fire 2024-01-12
26 health deficiencies
Top issue: Nutrition and Dietary (7 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Castro Valley, CA
East Bay Post-Acute
2-star overall rating with 1-star inspections with 26 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
20259 Lake Chabot Road, Castro Valley, CA
(510) 351-3700
Overall
2 / 5
CMS overall stars
Health inspections
1 / 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
91
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1972-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
0.81
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.89
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.66
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,078
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.19
Baseline 18.48% · Performance 20.42% · Measure score 2.19 · Achievement 2.19 · Improvement 0
Healthcare-associated infections
0.66
Baseline 9.27% · Performance 8.78% · Measure score 0.66 · Achievement 0 · Improvement 0.66
Total nurse turnover
2.41
Baseline 44.44% · Performance 53.85% · Measure score 2.41 · Achievement 2.41 · Improvement 0
Adjusted total nurse staffing
1.99
Baseline 3.84 hours · Performance 3.64 hours · Measure score 1.99 · Achievement 1.99 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.86% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 115 · Observed rate 13.91% · Lower 95% interval 9.13% |
| Discharge to community | 55.88% |
50.57%
5.3 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 50.44% · Lower 95% interval 48.53% |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 54 · Denominator 54 |
| Falls with major injury | 1.85% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 54 |
| Discharge self-care score | 59.38% |
53.69%
5.7 pts better
|
Numerator 19 · Denominator 32 |
| Discharge mobility score | 40.63% |
50.94%
10.3 pts worse
|
Numerator 13 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 2 · Denominator 54 · Adjusted rate 2.44% |
| Healthcare-associated infections requiring hospitalization | 8.78% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 12.66% · Lower 95% interval 6.19% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 80 |
| Staff flu vaccination coverage | 6.67% |
42%
35.3 pts worse
|
Numerator 9 · Denominator 135 |
| Discharge function score | 46.88% |
56.45%
9.6 pts worse
|
Numerator 15 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 91.3% |
96.28%
5 pts worse
|
Numerator 21 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 26.09% |
25.2%
0.9 pts better
|
Numerator 6 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.3
1.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.6
0.7 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
1.6%
0.8 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 1.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
6.8%
4.3 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 3.2% · Q4 4.8% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
4.1%
2.5 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.2% · Q3 0.0% · Q4 1.6% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.5% |
13.7%
5.2 pts better
|
19.6%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 9.1% · Q3 7.6% · Q4 6.1% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.3% |
14.2%
8.9 pts better
|
16.7%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.0% · Q3 5.8% · Q4 6.1% · 4Q avg 5.3% · 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 | 4.8% |
11.0%
6.2 pts better
|
16.3%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
10.7%
4.1 pts better
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.5% · Q3 5.6% · Q4 15.1% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 | 1.0% |
10.9%
9.9 pts better
|
19.8%
18.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 1.9% · 4Q avg 1.0% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
4.7%
0.5 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.5% · Q3 4.7% · Q4 1.1% · 4Q avg 4.2% · 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 | 27.0% |
11.2%
15.8 pts worse
|
12.0%
15 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.0% · Observed 25.4% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.5%
1 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.0% · Q3 2.3% · Q4 2.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.2% |
23.2%
12 pts better
|
23.9%
12.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 11.9% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-17 · Fire 2022-06-17
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2019-08-02 · Fire 2019-08-02
13 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
22 fire-safety deficiencies
Top issue: Emergency Preparedness (11 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-01-12
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-02-14
F · Potential for more than minimal harm
2024-01-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-12
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-02-14
D · Potential for more than minimal harm
2022-06-17
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-07-19
D · Potential for more than minimal harm
2022-06-17
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-07-19
D · Potential for more than minimal harm
2022-06-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-07-19
D · Potential for more than minimal harm
2022-06-17
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-07-19
D · Potential for more than minimal harm
2022-06-17
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-07-19
D · Potential for more than minimal harm
2022-06-17
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 2022-07-19
D · Potential for more than minimal harm
2022-06-17
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 2022-07-19
E · Potential for more than minimal harm
2019-08-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-10-09
E · Potential for more than minimal harm
2019-08-02
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2019-10-09
E · Potential for more than minimal harm
2019-08-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-09
E · Potential for more than minimal harm
2019-08-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
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 2019-10-09
D · Potential for more than minimal harm
2019-08-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
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 2019-10-09
D · Potential for more than minimal harm
2019-08-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-10-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-12
D · Potential for more than minimal harm
2024-10-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-05-16
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-05-30
G · Actual harm
2024-01-12
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 2024-02-12
G · Actual harm
2024-01-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-12
F · Potential for more than minimal harm
2024-01-12
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-02-12
F · Potential for more than minimal harm
2024-01-12
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 2024-02-12
F · Potential for more than minimal harm
2024-01-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-12
F · Potential for more than minimal harm
2024-01-12
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 2024-02-12
F · Potential for more than minimal harm
2024-01-12
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-02-12
E · Potential for more than minimal harm
2024-01-12
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 2024-02-12
E · Potential for more than minimal harm
2024-01-12
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-02-12
E · Potential for more than minimal harm
2024-01-12
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-02-12
E · Potential for more than minimal harm
2024-01-12
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 2024-02-12
E · Potential for more than minimal harm
2024-01-12
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 2024-02-12
E · Potential for more than minimal harm
2024-01-12
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 2024-02-12
E · Potential for more than minimal harm
2024-01-12
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 2024-02-12
E · Potential for more than minimal harm
2024-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-12
E · Potential for more than minimal harm
2024-01-12
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-02-12
D · Potential for more than minimal harm
2024-01-12
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 2024-02-12
D · Potential for more than minimal harm
2024-01-12
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 2024-02-12
D · Potential for more than minimal harm
2024-01-12
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2024-02-12
D · Potential for more than minimal harm
2024-01-12
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 2024-02-12
D · Potential for more than minimal harm
2024-01-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-12
D · Potential for more than minimal harm
2024-01-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-12
D · Potential for more than minimal harm
2024-01-12
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 2024-02-12
D · Potential for more than minimal harm
2024-01-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-12
D · Potential for more than minimal harm
2024-01-12
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 2024-02-12
D · Potential for more than minimal harm
2024-01-12
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-02-12
B · Minimal harm
2024-01-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-02-12
D · Potential for more than minimal harm
2023-09-20
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 2023-10-13
E · Potential for more than minimal harm
2022-06-17
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 2022-07-18
E · Potential for more than minimal harm
2022-06-17
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 2022-07-18
D · Potential for more than minimal harm
2022-06-17
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-06-17
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-06-17
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 2022-07-18
D · Potential for more than minimal harm
2022-06-17
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 2022-07-18
D · Potential for more than minimal harm
2022-06-17
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-06-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-18
E · Potential for more than minimal harm
2019-08-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-02
D · Potential for more than minimal harm
2019-08-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-09-02
D · Potential for more than minimal harm
2019-08-02
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 2019-09-02
D · Potential for more than minimal harm
2019-08-02
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 2019-09-02
D · Potential for more than minimal harm
2019-08-02
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 2019-09-02
D · Potential for more than minimal harm
2019-08-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-09-02
D · Potential for more than minimal harm
2019-08-02
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2019-09-02
D · Potential for more than minimal harm
2019-08-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-09-02
D · Potential for more than minimal harm
2019-08-02
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 2019-09-02
D · Potential for more than minimal harm
2019-08-02
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 2019-09-02
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Dhugga, Gurpreet
Contracted Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Oyler, Abraham
Contracted Managing Employee · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
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5-star overall rating with 4-star inspections with $10,033 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Baywood Court Health Center
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5-star overall rating with 5-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
St John Kronstadt Convalescent Center
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3-star overall rating with 2-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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