Cycle 1
Health 2025-02-07 · Fire 2025-02-07
14 health deficiencies
Top issue: Environmental (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Rosemead, CA
Green Acres Healthcare Center
1-star overall rating with 1-star inspections with $81,856 in total fines with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
8101 E Hill Drive, Rosemead, CA
(626) 280-2293
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
85
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Longwood Management Corporation
Operator or chain grouping
Approved since
2000-03-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 2 overall / 2 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
0.47
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.67
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.97
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
5.18
CMS adjusted total nurse staffing hours
Case-mix index
1.05
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,069
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.29
Composite VBP score used to determine payment impact.
Payment multiplier
1.0154
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.91
Baseline 19.25% · Performance 17.77% · Measure score 7.91 · Achievement 7.91 · Improvement 6.18
Healthcare-associated infections
3.85
Baseline 6.25% · Performance 6.68% · Measure score 3.85 · Achievement 3.85 · Improvement 0
Total nurse turnover
5.63
Baseline 53.85% · Performance 40.66% · Measure score 5.63 · Achievement 5.63 · Improvement 4.05
Adjusted total nurse staffing
6.72
Baseline 5.03 hours · Performance 4.99 hours · Measure score 6.72 · Achievement 6.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.71% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 203 · Observed rate 3.45% · Lower 95% interval 6.18% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 11.56% |
95.27%
83.7 pts worse
|
Numerator 17 · Denominator 147 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 147 |
| Discharge self-care score | 78.43% |
53.69%
24.7 pts better
|
Numerator 80 · Denominator 102 |
| Discharge mobility score | 82.35% |
50.94%
31.4 pts better
|
Numerator 84 · Denominator 102 |
| Pressure ulcers or injuries, new or worsened | 0.68% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 147 · Adjusted rate 0.96% |
| Healthcare-associated infections requiring hospitalization | 6.68% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 3.76% · Lower 95% interval 3.69% |
| Staff COVID-19 vaccination coverage | 18.81% |
8.2%
10.6 pts better
|
Numerator 19 · Denominator 101 |
| Staff flu vaccination coverage | 38.93% |
42%
3.1 pts worse
|
Numerator 58 · Denominator 149 |
| Discharge function score | 60.78% |
56.45%
4.3 pts better
|
Numerator 62 · Denominator 102 |
| Transfer of health information to provider | 94% |
95.95%
2 pts worse
|
Numerator 47 · Denominator 50 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 58.67% |
25.2%
33.5 pts better
|
Numerator 44 · Denominator 75 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.6 |
2.3
1.3 pts worse
|
1.9
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 4.9 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.6 · Expected 2.1 · 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 | 1.0% |
1.6%
0.6 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 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 who lose too much weight | 4.7% |
4.1%
0.6 pts worse
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.7% · Q3 4.5% · Q4 6.6% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
13.7%
0.3 pts worse
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 13.7% · Q3 13.3% · Q4 16.2% · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 70.8% |
14.2%
56.6 pts worse
|
16.7%
54.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.7% · Q2 73.3% · Q3 67.9% · Q4 69.0% · 4Q avg 70.8% · 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 | 10.3% |
11.0%
0.7 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 23.0% · Q3 6.2% · Q4 6.8% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.4% |
10.7%
12.7 pts worse
|
14.9%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 25.4% · Q3 13.5% · Q4 34.2% · 4Q avg 23.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.2%
0.4 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.1% · Q3 0.0% · Q4 1.6% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.3% |
10.9%
4.6 pts better
|
19.8%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 10.9% · Q3 2.4% · Q4 5.3% · 4Q avg 6.3% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.7%
1.6 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 8.6% · Q3 0.0% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.9% |
11.2%
5.3 pts better
|
12.0%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.9% · Observed 6.3% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
23.2%
2.4 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 17.6% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
30 health deficiencies
Top issue: Pharmacy Service (6 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2021-11-05 · Fire 2021-11-05
28 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-05
F · Potential for more than minimal harm
2024-02-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-02-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-02-09
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-09
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-09
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-09
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 2024-03-27
D · Potential for more than minimal harm
2024-02-09
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-09
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-27
F · Potential for more than minimal harm
2021-11-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-26
E · Potential for more than minimal harm
2021-11-05
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-01-26
E · Potential for more than minimal harm
2021-11-05
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-01-26
E · Potential for more than minimal harm
2021-11-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-01-26
E · Potential for more than minimal harm
2021-11-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-01-26
D · Potential for more than minimal harm
2021-11-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-01-26
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-07
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 2025-03-05
E · Potential for more than minimal harm
2025-02-07
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-07
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 2025-03-05
D · Potential for more than minimal harm
2025-02-07
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 2025-03-05
D · Potential for more than minimal harm
2025-02-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-07
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-07
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 2025-03-05
D · Potential for more than minimal harm
2025-02-07
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 2025-03-05
D · Potential for more than minimal harm
2025-02-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-07
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 2025-03-05
D · 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
B · Minimal harm
2025-02-07
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 2025-03-05
B · Minimal harm
2025-02-07
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 2025-03-05
B · Minimal harm
2025-02-07
F913 · Environmental Deficiencies
Health
Provide bedrooms that have direct access to an exit hallway.
Corrected 2025-03-05
F · Potential for more than minimal harm
2024-02-09
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 2024-03-20
F · Potential for more than minimal harm
2024-02-09
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 2024-03-20
F · Potential for more than minimal harm
2024-02-09
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 2024-03-20
F · Potential for more than minimal harm
2024-02-09
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 2024-03-20
E · Potential for more than minimal harm
2024-02-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-09
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 2024-03-20
E · Potential for more than minimal harm
2024-02-09
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 2024-03-20
E · Potential for more than minimal harm
2024-02-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-09
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 2024-03-20
E · Potential for more than minimal harm
2024-02-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-02-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-09
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-09
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 2024-03-20
E · Potential for more than minimal harm
2024-02-09
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-09
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 2024-03-20
D · Potential for more than minimal harm
2024-02-09
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 2024-04-05
D · Potential for more than minimal harm
2024-02-09
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 2024-03-20
D · Potential for more than minimal harm
2024-02-09
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 2024-03-20
D · Potential for more than minimal harm
2024-02-09
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 2024-03-20
D · Potential for more than minimal harm
2024-02-09
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-09
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 2024-03-20
D · Potential for more than minimal harm
2024-02-09
F907 · Environmental Deficiencies
Health
Provide enough space and equipment to meet each resident's needs
Corrected 2024-03-20
B · Minimal harm
2024-02-09
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 2024-03-20
B · Minimal harm
2024-02-09
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 2024-03-20
B · Minimal harm
2024-02-09
F913 · Environmental Deficiencies
Health
Provide bedrooms that have direct access to an exit hallway.
Corrected 2024-03-20
D · Potential for more than minimal harm
2023-12-15
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 2024-01-12
D · Potential for more than minimal harm
2023-12-15
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 2024-01-12
D · Potential for more than minimal harm
2023-06-16
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 2023-07-31
D · Potential for more than minimal harm
2023-06-16
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 2023-07-31
J · Immediate jeopardy
2023-05-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-15
J · Immediate jeopardy
2023-05-19
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-05-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-05-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-05-19
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 2023-06-15
D · Potential for more than minimal harm
2023-05-19
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 2023-06-15
E · Potential for more than minimal harm
2021-11-05
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 2021-12-23
E · Potential for more than minimal harm
2021-11-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-12-23
E · Potential for more than minimal harm
2021-11-05
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 2021-12-23
E · Potential for more than minimal harm
2021-11-05
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 2021-12-23
E · Potential for more than minimal harm
2021-11-05
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 2021-12-23
E · Potential for more than minimal harm
2021-11-05
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 2021-12-23
E · Potential for more than minimal harm
2021-11-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-23
D · Potential for more than minimal harm
2021-11-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-12-23
D · Potential for more than minimal harm
2021-11-05
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 2021-12-23
D · Potential for more than minimal harm
2021-11-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-12-23
D · Potential for more than minimal harm
2021-11-05
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 2021-12-23
D · Potential for more than minimal harm
2021-11-05
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 2021-12-23
D · Potential for more than minimal harm
2021-11-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-12-23
D · Potential for more than minimal harm
2021-11-05
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-12-23
D · Potential for more than minimal harm
2021-11-05
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 2021-12-23
B · Minimal harm
2021-11-05
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 2021-12-23
B · Minimal harm
2021-11-05
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 2021-12-23
B · Minimal harm
2021-11-05
F913 · Environmental Deficiencies
Health
Provide bedrooms that have direct access to an exit hallway.
Corrected 2021-12-23
Penalties and ownership
What sits behind the stars
$57,016
2024-02-09
Fine
Fine · fine $57,016
Fine
$0
2024-02-09
Payment Denial
Payment Denial · denial start 2024-03-12 · 24 days
24 day denial
$24,840
2023-05-19
Fine
Fine · fine $24,840
Fine
Ownership
Jrb Investments LLC
5% Or Greater Direct Ownership Interest · Organization
De Castro, Martin
Operational/Managerial Control · Individual
Friedman, Aaron
5% Or Greater Indirect Ownership Interest · Individual
Friedman, Ira
5% Or Greater Indirect Ownership Interest · Individual
Friedman, Ira
Operational/Managerial Control · Individual
Friedman, Ira
Corporate Director · Individual
Friedman, Ira
Corporate Officer · Individual
Klavan, Joshua
Operational/Managerial Control · Individual
Klavan, Rachel
5% Or Greater Indirect Ownership Interest · Individual
Klavan, Rachel
Corporate Director · Individual
Orquia, Joeffrey
Operational/Managerial Control · Individual
Pervaiz, Zaid
5% Or Greater Indirect Ownership Interest · Individual
The Aaron Friedman Group A Business Assets Trust
5% Or Greater Indirect Ownership Interest · Organization
The Ira David Friedman Group A Business Assets Trust
5% Or Greater Indirect Ownership Interest · Organization
The Libby Friedman Lehmann Group A Business Assets Trust
5% Or Greater Indirect Ownership Interest · Organization
The Ruchel Friedman Klavan Group A Business Assets Trust
5% Or Greater Indirect Ownership Interest · Organization
Xu, Jun
Operational/Managerial Control · Individual
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#3
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5-star overall rating with 4-star inspections with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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