Cycle 1
Health 2025-07-23 · Fire 2025-07-23
33 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Santa Ana, CA
French Park Care Center
2-star overall rating with 2-star inspections with 33 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
600 E Washington Avenue, Santa Ana, CA
(714) 973-1656
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
202
Certified beds
Average residents
183
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David & Frank Johnson
Operator or chain grouping
Approved since
1978-12-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
45 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
0.65
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.42
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.63
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.69
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.44
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.71
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,265
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.67
Baseline 20.05% · Performance 20.66% · Measure score 1.67 · Achievement 1.67 · Improvement 0
Healthcare-associated infections
0
Baseline 8.90% · Performance 8.90% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.53
Baseline 52.19% · Performance 36.99% · Measure score 6.53 · Achievement 6.53 · Improvement 5.06
Adjusted total nurse staffing
1.49
Baseline 3.27 hours · Performance 3.50 hours · Measure score 1.49 · Achievement 1.49 · Improvement 0.43
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.25% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 140 · Observed rate 14.29% · Lower 95% interval 8.23% |
| Discharge to community | 36.68% |
50.57%
13.9 pts worse
|
Worse than the National Rate · Eligible stays 122 · Observed rate 23.77% · Lower 95% interval 28.81% |
| Medicare spending per beneficiary | 1.44 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 99.56% |
95.27%
4.3 pts better
|
Numerator 227 · Denominator 228 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 228 |
| Discharge self-care score | 62.04% |
53.69%
8.4 pts better
|
Numerator 85 · Denominator 137 |
| Discharge mobility score | 52.55% |
50.94%
1.6 pts better
|
Numerator 72 · Denominator 137 |
| Pressure ulcers or injuries, new or worsened | 1.32% |
2.29%
1 pts better
|
Numerator 3 · Denominator 228 · Adjusted rate 0.98% |
| Healthcare-associated infections requiring hospitalization | 8.9% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 14.89% · Lower 95% interval 5.69% |
| Staff COVID-19 vaccination coverage | 10.53% |
8.2%
2.3 pts better
|
Numerator 34 · Denominator 323 |
| Staff flu vaccination coverage | 39.04% |
42%
3 pts worse
|
Numerator 162 · Denominator 415 |
| Discharge function score | 55.47% |
56.45%
1 pts worse
|
Numerator 76 · Denominator 137 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 114 · Denominator 114 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 48.31% |
25.2%
23.1 pts better
|
Numerator 57 · Denominator 118 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.3
0.6 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 4.8 · Expected 3.1 · 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 1.8 · Expected 2.0 · 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 | 2.1% |
1.6%
0.5 pts worse
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.3% · Q3 1.2% · Q4 3.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.9% |
6.8%
0.1 pts worse
|
11.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 6.7% · Q3 6.0% · Q4 8.1% · 4Q avg 6.9% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
4.1%
3.3 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 1.3% · Q4 1.3% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
13.7%
1.3 pts worse
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 12.3% · Q3 16.7% · Q4 22.1% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
14.2%
1.3 pts worse
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 8.4% · Q3 18.6% · Q4 22.4% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.0% |
0.4%
0.6 pts worse
|
0.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 1.8% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.5% |
11.0%
4.5 pts better
|
16.3%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 8.9% · Q3 10.0% · Q4 4.6% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
10.7%
2.7 pts better
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 11.5% · Q3 7.1% · Q4 5.9% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.0%
0.8 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.2%
1 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.4% |
10.9%
5.5 pts better
|
19.8%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.0% · Q3 3.2% · Q4 6.5% · 4Q avg 5.4% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
4.7%
1.3 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.7% · Q3 5.7% · Q4 7.2% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
94.0%
5.6 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 99.3% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
11.2%
3.8 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 8.6% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.5%
0.3 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.6% · Q3 1.3% · Q4 1.4% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
93.2%
5.2 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.8% |
23.2%
3.6 pts worse
|
23.9%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.8% · Observed 33.6% · Expected 29.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-31 · Fire 2023-10-31
43 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2021-10-22 · Fire 2021-10-22
31 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-04
F · Potential for more than minimal harm
2025-07-23
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-07-23
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-23
K233 · Egress Deficiencies
Fire Safety
Install resident room doors of proper design and width.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-07-23
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-07-31
F · Potential for more than minimal harm
2023-10-31
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-31
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-31
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-31
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-31
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-31
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-31
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-11-17
E · Potential for more than minimal harm
2021-10-22
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2021-11-15
E · Potential for more than minimal harm
2021-10-22
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2021-11-15
E · Potential for more than minimal harm
2021-10-22
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-11-15
E · Potential for more than minimal harm
2021-10-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-11-15
E · Potential for more than minimal harm
2021-10-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-22
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-22
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-22
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-22
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-22
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-11-15
Inspection history
Recent health citations
B · Minimal harm
2026-01-28
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 2026-02-17
D · Potential for more than minimal harm
2026-01-16
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 2026-01-21
D · Potential for more than minimal harm
2026-01-16
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-09-10
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 2025-09-25
D · Potential for more than minimal harm
2025-08-14
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-30
E · Potential for more than minimal harm
2025-07-23
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-08-23
E · Potential for more than minimal harm
2025-07-23
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-07-23
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-07-23
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-07-23
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 2025-08-23
D · Potential for more than minimal harm
2025-07-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-07-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-07-23
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 2025-08-23
D · Potential for more than minimal harm
2025-07-23
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 2025-08-23
D · Potential for more than minimal harm
2025-07-23
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 2025-08-23
D · Potential for more than minimal harm
2025-07-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-07-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-07-23
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 2025-08-23
D · Potential for more than minimal harm
2025-07-23
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 2025-08-23
D · Potential for more than minimal harm
2025-07-23
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 2025-08-23
D · Potential for more than minimal harm
2025-07-23
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 2025-08-23
D · Potential for more than minimal harm
2025-07-23
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-07-23
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-07-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-07-23
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-08-23
B · Minimal harm
2025-07-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-08-23
B · Minimal harm
2025-07-23
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 2025-08-23
B · Minimal harm
2025-07-23
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 2025-08-23
B · Minimal harm
2025-07-23
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2025-08-23
B · Minimal harm
2025-07-23
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 2025-08-23
D · Potential for more than minimal harm
2025-06-17
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 2025-07-04
D · Potential for more than minimal harm
2025-03-14
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-02-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-02-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-24
D · Potential for more than minimal harm
2024-06-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-02
B · Minimal harm
2024-06-06
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 2024-07-02
D · Potential for more than minimal harm
2024-05-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-05-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-04-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-13
B · Minimal harm
2024-04-19
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-05-13
B · Minimal harm
2024-04-19
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 2024-05-13
D · Potential for more than minimal harm
2024-03-13
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 2024-03-31
B · Minimal harm
2024-03-13
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 2024-03-31
D · Potential for more than minimal harm
2024-02-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-01
B · Minimal harm
2024-01-25
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 2024-02-11
B · Minimal harm
2024-01-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-20
E · Potential for more than minimal harm
2023-10-31
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 2023-11-30
E · Potential for more than minimal harm
2023-10-31
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 2023-11-30
E · Potential for more than minimal harm
2023-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-10-31
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
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 2023-11-30
D · Potential for more than minimal harm
2023-10-31
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 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
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 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
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 2023-11-30
D · Potential for more than minimal harm
2023-10-31
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 2023-11-30
D · Potential for more than minimal harm
2023-10-31
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 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
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 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-11-30
B · Minimal harm
2023-10-31
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 2023-11-30
B · Minimal harm
2023-10-31
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 2023-11-30
B · Minimal harm
2023-10-31
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 2023-11-30
B · Minimal harm
2023-10-31
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-11-30
B · Minimal harm
2023-10-31
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 2023-11-30
B · Minimal harm
2023-10-04
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 2023-10-23
B · Minimal harm
2023-10-04
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 2023-10-23
E · Potential for more than minimal harm
2023-07-19
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-08-07
E · Potential for more than minimal harm
2023-07-19
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-19
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 2023-08-07
D · Potential for more than minimal harm
2023-07-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-19
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-06-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-11
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 2023-05-23
D · Potential for more than minimal harm
2023-03-24
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 2023-04-10
D · Potential for more than minimal harm
2023-03-24
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 2023-04-10
E · Potential for more than minimal harm
2021-10-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-11-20
E · Potential for more than minimal harm
2021-10-22
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 2021-11-20
D · Potential for more than minimal harm
2021-10-22
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 2021-11-20
D · Potential for more than minimal harm
2021-10-22
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2021-11-20
D · Potential for more than minimal harm
2021-10-22
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 2021-11-20
D · Potential for more than minimal harm
2021-10-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-11-20
D · Potential for more than minimal harm
2021-10-22
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 2021-11-20
D · Potential for more than minimal harm
2021-10-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-11-20
D · Potential for more than minimal harm
2021-10-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-11-20
D · Potential for more than minimal harm
2021-10-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-11-20
D · Potential for more than minimal harm
2021-10-22
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 2021-11-20
D · Potential for more than minimal harm
2021-10-22
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 2021-11-20
D · Potential for more than minimal harm
2021-10-22
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 2021-11-20
D · Potential for more than minimal harm
2021-10-22
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 2021-11-20
D · Potential for more than minimal harm
2021-10-22
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2021-11-20
D · Potential for more than minimal harm
2021-10-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-20
D · Potential for more than minimal harm
2021-10-22
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-11-20
Penalties and ownership
What sits behind the stars
Ownership
Bauman, Irving
5% Or Greater Direct Ownership Interest · Individual
Dehghanmanesh, Adrian
Corporate Officer · Individual
Johnson, Frank
5% Or Greater Direct Ownership Interest · Individual
Johnson, Frank
Corporate Officer · Individual
Kimball, John
W-2 Managing Employee · Individual
Marmur, Eli
5% Or Greater Direct Ownership Interest · Individual
Muir, Smita
5% Or Greater Direct Ownership Interest · Individual
Presnell, William
Operational/Managerial Control · Individual
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