Cycle 1
Health 2024-12-12 · Fire 2024-12-12
16 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Long Beach, CA
Edgewater Skilled Nursing Center
2-star overall rating with 2-star inspections with $65,656 in total fines with 15 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2625 East Fourth Street, Long Beach, CA
(562) 434-0974
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
81
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1973-12-01
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.37
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.93
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,364
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.14
Baseline 17.43% · Performance 18.12% · Measure score 7.14 · Achievement 7.14 · Improvement 0
Healthcare-associated infections
0
Baseline 5.16% · Performance 8.68% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 42.47% · Performance 64.05% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.66
Baseline 4.10 hours · Performance 4.12 hours · Measure score 3.66 · Achievement 3.66 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.04% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 135 · Observed rate 7.41% · Lower 95% interval 6.8% |
| Discharge to community | 47.76% |
50.57%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 109 · Observed rate 41.28% · Lower 95% interval 38.41% |
| Medicare spending per beneficiary | 1.5 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 98.86% |
95.27%
3.6 pts better
|
Numerator 87 · Denominator 88 |
| Falls with major injury | 1.14% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 88 |
| Discharge self-care score | 34.88% |
53.69%
18.8 pts worse
|
Numerator 15 · Denominator 43 |
| Discharge mobility score | 37.21% |
50.94%
13.7 pts worse
|
Numerator 16 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 3.41% |
2.29%
1.1 pts worse
|
Numerator 3 · Denominator 88 · Adjusted rate 3.1% |
| Healthcare-associated infections requiring hospitalization | 8.68% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 13.4% · Lower 95% interval 6.06% |
| Staff COVID-19 vaccination coverage | 4.64% |
8.2%
3.6 pts worse
|
Numerator 7 · Denominator 151 |
| Staff flu vaccination coverage | 41.98% |
42%
About the same
|
Numerator 68 · Denominator 162 |
| Discharge function score | 41.86% |
56.45%
14.6 pts worse
|
Numerator 18 · Denominator 43 |
| Transfer of health information to provider | 96.77% |
95.95%
0.8 pts better
|
Numerator 30 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 22.22% |
25.2%
3 pts worse
|
Numerator 12 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.3
0.4 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.5 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
98.5%
0.6 pts worse
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 98.5% · Q3 98.1% · Q4 98.3% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.3% |
98.2%
7.9 pts worse
|
95.5%
5.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| 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 1.5% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.0% |
6.8%
0.2 pts worse
|
11.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.6% · Q3 7.0% · Q4 16.7% · 4Q avg 7.0% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
4.1%
2.8 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 0.0% · Q4 2.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.7% |
13.7%
5 pts better
|
19.6%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 9.2% · Q3 9.4% · Q4 10.0% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
14.2%
2.4 pts better
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 5.4% · Q3 11.8% · Q4 17.1% · 4Q avg 11.8% · 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 | 4.9% |
11.0%
6.1 pts better
|
16.3%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.0% |
10.7%
1.3 pts worse
|
14.9%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 8.5% · Q3 11.1% · Q4 22.6% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.1% |
1.0%
3.1 pts worse
|
1.0%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 4.5% · Q3 4.6% · Q4 4.6% · 4Q avg 4.1% · 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 | 15.0% |
10.9%
4.1 pts worse
|
19.8%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 16.5% · Q3 19.2% · Q4 17.1% · 4Q avg 15.0% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
4.7%
3.6 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 10.6% · Q3 7.3% · Q4 5.2% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
94.0%
5.4 pts worse
|
81.7%
6.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 70.4% · Q2 94.5% · Q3 91.8% · Q4 93.3% · 4Q avg 88.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
11.2%
2.3 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 10.3% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.1% |
1.5%
5.6 pts worse
|
1.6%
5.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.7% · Q3 7.4% · Q4 8.2% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.0% |
93.2%
4.2 pts worse
|
79.7%
9.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
23.2%
0.7 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 26.5% · Expected 28.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-29 · Fire 2023-12-29
38 health deficiencies
Top issue: Resident Rights (13 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-01-13 · Fire 2023-01-13
20 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-12
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 2025-01-06
E · Potential for more than minimal harm
2024-12-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-06
E · Potential for more than minimal harm
2023-12-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-06
E · Potential for more than minimal harm
2023-12-29
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-03-06
D · Potential for more than minimal harm
2023-12-29
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-03-06
D · Potential for more than minimal harm
2023-12-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-06
D · Potential for more than minimal harm
2023-12-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-06
E · Potential for more than minimal harm
2023-01-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-31
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-31
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-05-23
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-02-07
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-01-24
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 2025-02-14
E · Potential for more than minimal harm
2025-01-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-17
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 2025-02-11
E · Potential for more than minimal harm
2025-01-08
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 2025-01-31
D · Potential for more than minimal harm
2025-01-08
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 2025-01-31
E · Potential for more than minimal harm
2024-12-12
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 2025-01-06
D · Potential for more than minimal harm
2024-12-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-12
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-12
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 2025-01-06
D · Potential for more than minimal harm
2024-12-12
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 2025-01-06
D · Potential for more than minimal harm
2024-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-12
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 2025-01-06
D · Potential for more than minimal harm
2024-12-12
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-12
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 2025-01-06
D · Potential for more than minimal harm
2024-12-12
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 2025-01-06
D · Potential for more than minimal harm
2024-12-12
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 2025-01-06
D · Potential for more than minimal harm
2024-12-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-12
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 2025-01-06
F · Potential for more than minimal harm
2024-12-04
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-12-04
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 2024-12-26
D · Potential for more than minimal harm
2024-12-04
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-12-04
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 2024-12-26
D · Potential for more than minimal harm
2024-09-03
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 2024-09-26
D · Potential for more than minimal harm
2024-09-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-09-03
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 2024-09-26
D · Potential for more than minimal harm
2024-09-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-12
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-06-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-06-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-15
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-03
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-05-23
G · Actual harm
2024-05-02
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 2024-05-30
D · Potential for more than minimal harm
2024-05-02
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 2024-05-30
E · Potential for more than minimal harm
2024-04-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-26
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 2024-04-10
E · Potential for more than minimal harm
2024-03-05
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 2024-03-22
E · Potential for more than minimal harm
2024-03-05
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 2024-03-22
D · Potential for more than minimal harm
2024-03-05
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-03-05
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-03-05
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-03-05
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 2024-03-22
D · Potential for more than minimal harm
2024-03-05
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 2024-03-22
D · Potential for more than minimal harm
2024-01-30
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 2024-02-21
D · Potential for more than minimal harm
2024-01-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-21
E · Potential for more than minimal harm
2023-12-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-01-18
E · Potential for more than minimal harm
2023-12-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-01-18
E · Potential for more than minimal harm
2023-12-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-18
B · Minimal harm
2023-12-29
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-01-18
E · Potential for more than minimal harm
2023-09-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-16
K · Immediate jeopardy
2023-08-21
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 2023-09-20
E · 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 2023-09-20
E · Potential for more than minimal harm
2023-01-13
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 2023-02-09
E · Potential for more than minimal harm
2023-01-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-09
E · Potential for more than minimal harm
2023-01-13
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 2023-02-09
E · Potential for more than minimal harm
2023-01-13
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 2023-02-09
E · Potential for more than minimal harm
2023-01-13
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 2023-02-09
E · Potential for more than minimal harm
2023-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-01-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-01-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-01-13
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-01-13
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 2023-02-09
D · Potential for more than minimal harm
2023-01-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-01-13
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 2023-02-09
D · Potential for more than minimal harm
2023-01-13
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 2023-02-09
B · Minimal harm
2023-01-13
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2023-02-09
Penalties and ownership
What sits behind the stars
$0
2024-12-04
Payment Denial
Payment Denial · denial start 2025-03-04 · 1 days
1 day denial
$8,990
2024-03-05
Fine
Fine · fine $8,990
Fine
$51,773
2023-08-21
Fine
Fine · fine $51,773
Fine
$1,748
2023-06-26
Fine
Fine · fine $1,748
Fine
$3,145
2023-06-05
Fine
Fine · fine $3,145
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
Dalton, Kyle
Operational/Managerial Control · Individual
Dalton, Kyle
W-2 Managing Employee · Individual
Fitch, Craig
Corporate Officer · Individual
Kim, Jesse
Corporate Officer · Individual
Willits, Adam
Corporate Director · Individual
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#3
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