Cycle 1
Health 2024-12-09 · Fire 2024-12-09
25 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Los Alamos, NM
Los Alamos Wellness & Rehabilitation
1-star overall rating with 1-star inspections with $95,761 in total fines with 25 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1011 Sombrillo Court, Los Alamos, NM
(505) 662-4300
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
60
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Opco Skilled Management
Operator or chain grouping
Approved since
1991-10-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.56 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.33 · national 1.54
Weekend hours
2.91
Weekend nurse staffing · state 3.12 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 54% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,683
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.58
Baseline 20.76% · Performance 21.16% · Measure score 0.58 · Achievement 0.58 · Improvement 0
Healthcare-associated infections
1.02
Baseline 8.32% · Performance 7.81% · Measure score 1.02 · Achievement 0 · Improvement 1.02
Total nurse turnover
6.37
Baseline 91.78% · Performance 45.83% · Measure score 6.37 · Achievement 4.37 · Improvement 6.37
Adjusted total nurse staffing
1.18
Baseline 3.72 hours · Performance 3.41 hours · Measure score 1.18 · Achievement 1.18 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.62% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 8.85% · Lower 95% interval 7.35% |
| Discharge to community | 53.78% |
50.57%
3.2 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 50.5% · Lower 95% interval 44.04% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 77.67% |
95.27%
17.6 pts worse
|
Numerator 80 · Denominator 103 |
| Falls with major injury | 1.94% |
0.77%
1.2 pts worse
|
Numerator 2 · Denominator 103 |
| Discharge self-care score | 75.36% |
53.69%
21.7 pts better
|
Numerator 52 · Denominator 69 |
| Discharge mobility score | 79.71% |
50.94%
28.8 pts better
|
Numerator 55 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 3.88% |
2.29%
1.6 pts worse
|
Numerator 4 · Denominator 103 · Adjusted rate 4.21% |
| Healthcare-associated infections requiring hospitalization | 7.82% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 8% · Lower 95% interval 5.03% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 86.96% |
56.45%
30.5 pts better
|
Numerator 60 · Denominator 69 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | 91.04% |
96.28%
5.2 pts worse
|
Numerator 61 · Denominator 67 |
| Resident COVID-19 vaccinations up to date | 54.55% |
25.2%
29.3 pts better
|
Numerator 30 · Denominator 55 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.6
0.9 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.4 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
2.6
0.8 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 2.2 · Expected 1.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.4%
2.6 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% |
98.7%
1.3 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 | 6.0% |
3.5%
2.5 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.2% · Q3 6.5% · Q4 9.5% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.8%
1.8 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 | 1.2% |
5.4%
4.2 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.6% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.4% |
14.1%
11.7 pts better
|
19.6%
17.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.3% · Q3 4.8% · Q4 0.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
14.7%
3.6 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 21.4% · Q3 9.4% · Q4 3.8% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 7.5% |
15.8%
8.3 pts better
|
16.3%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.0% · Q3 11.4% · Q4 6.9% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.7% |
14.6%
7.9 pts better
|
14.9%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 9.3% · Q3 11.9% · Q4 2.7% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 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 | 0.6% |
0.9%
0.3 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.7% |
20.6%
11.9 pts better
|
19.8%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.0% · Q3 8.8% · Q4 7.8% · 4Q avg 8.7% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.7%
0.6 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 5.1% · Q3 8.1% · Q4 5.3% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
86.6%
10.8 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 96.3% · Q3 98.3% · Q4 96.1% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
15.9%
6.8 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.2% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
86.4%
12.7 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
21.3%
1.3 pts worse
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 18.8% · Expected 19.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
22 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-08-11 · Fire 2022-08-11
26 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-12-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-12-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-18
F · Potential for more than minimal harm
2023-10-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-10-26
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 2023-12-01
F · Potential for more than minimal harm
2023-10-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-01
F · Potential for more than minimal harm
2022-08-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-08-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-08-11
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 2022-09-09
E · Potential for more than minimal harm
2022-08-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-08-11
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-09-09
Inspection history
Recent health citations
K · Immediate jeopardy
2025-12-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-18
E · Potential for more than minimal harm
2025-12-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-02-18
E · Potential for more than minimal harm
2025-12-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-18
E · Potential for more than minimal harm
2025-12-19
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 2026-02-18
E · Potential for more than minimal harm
2025-12-19
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 2026-02-18
E · Potential for more than minimal harm
2025-06-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-21
E · Potential for more than minimal harm
2025-03-24
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 2025-04-18
D · Potential for more than minimal harm
2025-03-24
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-24
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 2025-04-18
D · Potential for more than minimal harm
2025-03-24
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 2025-04-18
D · Potential for more than minimal harm
2025-03-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-24
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 2025-04-18
D · Potential for more than minimal harm
2025-03-24
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 2025-04-18
F · Potential for more than minimal harm
2024-12-09
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 2024-12-18
F · Potential for more than minimal harm
2024-12-09
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 2024-12-18
F · Potential for more than minimal harm
2024-12-09
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 2024-12-18
F · Potential for more than minimal harm
2024-12-09
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-12-09
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 2024-12-18
E · Potential for more than minimal harm
2024-12-09
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 2024-12-18
E · Potential for more than minimal harm
2024-12-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-12-09
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 2024-12-18
E · Potential for more than minimal harm
2024-12-09
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 2024-12-18
D · Potential for more than minimal harm
2024-12-09
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 2024-12-18
D · Potential for more than minimal harm
2024-12-09
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-12-09
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 2024-12-18
D · Potential for more than minimal harm
2024-08-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-22
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-03-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-18
F · Potential for more than minimal harm
2023-10-26
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-10-26
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 2023-12-01
F · Potential for more than minimal harm
2023-10-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-26
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-26
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 2023-12-01
E · Potential for more than minimal harm
2023-10-26
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 2023-12-01
E · Potential for more than minimal harm
2023-10-26
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 2023-12-01
E · Potential for more than minimal harm
2023-10-26
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 2023-12-01
D · Potential for more than minimal harm
2023-10-26
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-26
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 2023-12-01
D · Potential for more than minimal harm
2023-10-26
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 2023-12-01
D · Potential for more than minimal harm
2023-10-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-26
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 2023-12-01
D · Potential for more than minimal harm
2023-10-26
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 2023-12-01
D · Potential for more than minimal harm
2023-10-26
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 2023-10-26
D · Potential for more than minimal harm
2023-10-26
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-12-01
F · Potential for more than minimal harm
2022-08-11
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 2022-09-21
F · Potential for more than minimal harm
2022-08-11
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2022-09-21
F · Potential for more than minimal harm
2022-08-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-09-21
F · Potential for more than minimal harm
2022-08-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-21
E · Potential for more than minimal harm
2022-08-11
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 2022-09-21
E · Potential for more than minimal harm
2022-08-11
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 2022-09-21
E · Potential for more than minimal harm
2022-08-11
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 2022-09-21
E · Potential for more than minimal harm
2022-08-11
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 2022-09-21
E · Potential for more than minimal harm
2022-08-11
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 2022-09-21
E · Potential for more than minimal harm
2022-08-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-09-21
E · Potential for more than minimal harm
2022-08-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-21
E · Potential for more than minimal harm
2022-08-11
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 2022-09-21
E · Potential for more than minimal harm
2022-08-11
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 2022-09-21
E · Potential for more than minimal harm
2022-08-11
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 2022-09-21
D · Potential for more than minimal harm
2022-08-11
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 2022-09-21
D · Potential for more than minimal harm
2022-08-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-09-21
D · Potential for more than minimal harm
2022-08-11
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 2022-09-21
D · Potential for more than minimal harm
2022-08-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-09-21
D · Potential for more than minimal harm
2022-08-11
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2022-09-21
D · Potential for more than minimal harm
2022-08-11
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-09-21
D · Potential for more than minimal harm
2022-08-11
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-09-21
D · Potential for more than minimal harm
2022-08-11
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 2022-09-21
D · Potential for more than minimal harm
2022-08-11
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 2022-09-21
D · Potential for more than minimal harm
2022-08-11
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-09-21
Penalties and ownership
What sits behind the stars
$20,390
2025-12-19
Fine
Fine · fine $20,390
Fine
$26,685
2025-12-19
Fine
Fine · fine $26,685
Fine
$4,938
2024-02-12
Fine
Fine · fine $4,938
Fine
$14,814
2024-01-22
Fine
Fine · fine $14,814
Fine
$14,113
2023-12-26
Fine
Fine · fine $14,113
Fine
$4,235
2023-08-28
Fine
Fine · fine $4,235
Fine
$10,586
2023-08-07
Fine
Fine · fine $10,586
Fine
Ownership
Casa Healthcare, LLC
Operational/Managerial Control · Organization
Garetz, David
Operational/Managerial Control · Individual
Garetz, David
Corporate Officer · Individual
Hansen Hunter LLC
Operational/Managerial Control · Organization
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#3
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