Cycle 1
Health 2024-09-13 · Fire 2024-09-13
18 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fresno, CA
Grace Healthcare Center
1-star overall rating with 1-star inspections with abuse icon flag with $50,106 in total fines with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2939 S. Peach Avenue, Fresno, CA
(559) 233-6248
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.79
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.03
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.52
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.87
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
0.00
Reported PT staffing
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
4.10
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,428
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.80
Performance 56.34% · Measure score 1.80 · Achievement 1.80 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.94
Performance 3.91 hours · Measure score 2.94 · Achievement 2.94 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 10 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 8.79% |
8.2%
0.6 pts better
|
Numerator 8 · Denominator 91 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.3
0.7 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 1.9 · Expected 1.2 · 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 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
98.5%
0.7 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.6% · 4Q avg 99.2% |
| 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 | 0.4% |
1.6%
1.2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.9% |
6.8%
6.1 pts worse
|
11.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 14.0% · Q3 18.9% · Q4 18.0% · 4Q avg 12.9% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
4.1%
2.2 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 0.0% · Q4 3.7% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.6% |
13.7%
10.9 pts worse
|
19.6%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 23.2% · Q3 25.5% · Q4 26.3% · 4Q avg 24.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
14.2%
3 pts worse
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q3 18.5% · Q4 18.5% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.5% |
11.0%
10.5 pts worse
|
16.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
10.7%
4.4 pts better
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 6.2% · Q3 10.4% · Q4 4.2% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.0%
0.1 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.2%
0.3 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 1.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.2% |
10.9%
5.7 pts better
|
19.8%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 6.4% · Q4 13.6% · 4Q avg 5.2% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.7%
0.4 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.0% · Q3 4.5% · Q4 4.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.0% |
94.0%
8 pts worse
|
81.7%
4.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 86.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-16 · Fire 2023-06-16
31 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
21 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Cycle 3
Health 2019-10-31 · Fire 2019-10-31
21 health deficiencies
Top issue: Resident Rights (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-13
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 2024-10-10
E · Potential for more than minimal harm
2024-09-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-10
F · Potential for more than minimal harm
2023-06-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-21
F · Potential for more than minimal harm
2023-06-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-21
F · Potential for more than minimal harm
2023-06-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-21
F · Potential for more than minimal harm
2023-06-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-06-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-06-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-06-16
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-06-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-06-16
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-16
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-16
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-21
C · Minimal harm
2023-06-16
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-07-21
C · Minimal harm
2023-06-16
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-07-21
C · Minimal harm
2023-06-16
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-07-21
C · Minimal harm
2023-06-16
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-07-21
C · Minimal harm
2023-06-16
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-07-21
E · Potential for more than minimal harm
2019-10-31
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-12-31
E · Potential for more than minimal harm
2019-10-31
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2019-12-31
E · Potential for more than minimal harm
2019-10-31
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-12-31
E · Potential for more than minimal harm
2019-10-31
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 2019-12-31
E · Potential for more than minimal harm
2019-10-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-12-31
E · Potential for more than minimal harm
2019-10-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-12-31
E · Potential for more than minimal harm
2019-10-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-31
E · Potential for more than minimal harm
2019-10-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-12-31
E · Potential for more than minimal harm
2019-10-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-31
E · Potential for more than minimal harm
2019-10-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-12-31
D · Potential for more than minimal harm
2019-10-31
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-12-31
Inspection history
Recent health citations
G · Actual harm
2025-09-05
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 2025-10-15
D · Potential for more than minimal harm
2024-12-23
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-01-23
F · Potential for more than minimal harm
2024-10-02
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-02
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 2024-11-15
E · Potential for more than minimal harm
2024-10-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-02
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-02
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-02
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-02
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-02
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-09-13
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 2024-10-15
F · Potential for more than minimal harm
2024-09-13
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 2024-10-15
F · Potential for more than minimal harm
2024-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-09-13
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-09-13
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 2024-10-15
E · Potential for more than minimal harm
2024-09-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-09-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-09-13
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 2024-10-15
D · Potential for more than minimal harm
2024-09-13
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 2024-10-15
D · Potential for more than minimal harm
2024-09-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-09-13
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 2024-10-15
D · Potential for more than minimal harm
2024-09-13
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 2024-10-15
D · Potential for more than minimal harm
2024-09-13
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 2024-10-15
D · Potential for more than minimal harm
2024-09-13
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 2024-10-15
D · Potential for more than minimal harm
2024-09-13
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 2024-10-15
D · Potential for more than minimal harm
2024-09-13
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-10-15
C · Minimal harm
2024-09-13
F911 · Environmental Deficiencies
Health
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-05-16
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 2024-06-04
D · Potential for more than minimal harm
2024-01-04
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2024-03-01
E · Potential for more than minimal harm
2023-08-22
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-08-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-06-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-06-16
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 2023-08-01
F · Potential for more than minimal harm
2023-06-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-16
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 2023-08-01
E · Potential for more than minimal harm
2023-06-16
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-16
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 2023-08-01
E · Potential for more than minimal harm
2023-06-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-16
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 2023-08-01
E · Potential for more than minimal harm
2023-06-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-16
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 2023-08-01
E · Potential for more than minimal harm
2023-06-16
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 2023-08-01
E · Potential for more than minimal harm
2023-06-16
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-16
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 2023-08-01
D · Potential for more than minimal harm
2023-06-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-16
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-16
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-01
B · Minimal harm
2023-06-16
F911 · Environmental Deficiencies
Health
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-30
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 2023-07-14
D · Potential for more than minimal harm
2023-05-30
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 2023-07-14
F · Potential for more than minimal harm
2023-04-05
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-04-16
E · Potential for more than minimal harm
2023-04-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-16
E · Potential for more than minimal harm
2023-03-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-04-05
E · Potential for more than minimal harm
2023-03-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-05
E · Potential for more than minimal harm
2023-03-16
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-04-05
F · Potential for more than minimal harm
2019-10-31
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2020-02-21
F · Potential for more than minimal harm
2019-10-31
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 2020-02-21
F · Potential for more than minimal harm
2019-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-21
E · Potential for more than minimal harm
2019-10-31
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 2020-02-21
E · Potential for more than minimal harm
2019-10-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-02-21
E · Potential for more than minimal harm
2019-10-31
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-02-21
E · Potential for more than minimal harm
2019-10-31
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 2020-02-21
E · Potential for more than minimal harm
2019-10-31
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 2020-02-21
D · Potential for more than minimal harm
2019-10-31
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 2020-02-21
D · Potential for more than minimal harm
2019-10-31
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 2020-02-21
B · Minimal harm
2019-10-31
F911 · Environmental Deficiencies
Health
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Corrected 2020-02-21
Penalties and ownership
What sits behind the stars
$0
2025-09-05
Payment Denial
Payment Denial · denial start 2025-10-11 · 4 days
4 day denial
$4,587
2023-09-05
Fine
Fine · fine $4,587
Fine
$4,587
2023-08-28
Fine
Fine · fine $4,587
Fine
$4,587
2023-08-21
Fine
Fine · fine $4,587
Fine
$4,587
2023-08-14
Fine
Fine · fine $4,587
Fine
$13,762
2023-07-17
Fine
Fine · fine $13,762
Fine
$4,587
2023-06-26
Fine
Fine · fine $4,587
Fine
$0
2023-05-30
Payment Denial
Payment Denial · denial start 2023-08-30 · 6 days
6 day denial
$13,409
2023-05-15
Fine
Fine · fine $13,409
Fine
Ownership
Gonzalez, Llatisha
5% Or Greater Direct Ownership Interest · Individual
Gonzalez, Llatisha
Corporate Director · Individual
Gonzalez, Llatisha
Corporate Officer · Individual
Gonzalez, Llatisha
W-2 Managing Employee · Individual
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#3
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2-star overall rating with 2-star inspections with $30,654 in total fines with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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