Cycle 1
Health 2025-02-21 · Fire 2025-02-21
18 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Culver City, CA
Marina Pointe Healthcare & Subacute
2-star overall rating with 2-star inspections with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
5240 Sepulveda Blvd, Culver City, CA
(310) 391-7266
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aspen Skilled Healthcare
Operator or chain grouping
Approved since
1989-03-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 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
0.55
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.74
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.70
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.29
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.35
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.30
CMS adjusted total nurse staffing hours
Case-mix index
1.95
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,337
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9933
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.83
Baseline 24.75% · Performance 20.63% · Measure score 4.83 · Achievement 1.73 · Improvement 4.83
Healthcare-associated infections
5.28
Baseline 10.42% · Performance 7.29% · Measure score 5.28 · Achievement 1.84 · Improvement 5.28
Total nurse turnover
5.45
Baseline 45.05% · Performance 41.41% · Measure score 5.45 · Achievement 5.45 · Improvement 1.30
Adjusted total nurse staffing
0.59
Baseline 3.24 hours · Performance 3.24 hours · Measure score 0.59 · Achievement 0.59 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.63% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 174 · Observed rate 17.24% · Lower 95% interval 9.24% |
| Discharge to community | 37.95% |
50.57%
12.6 pts worse
|
Worse than the National Rate · Eligible stays 144 · Observed rate 22.22% · Lower 95% interval 29.65% |
| Medicare spending per beneficiary | 1.5 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 99.35% |
95.27%
4.1 pts better
|
Numerator 152 · Denominator 153 |
| Falls with major injury | 0.65% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 153 |
| Discharge self-care score | 50.7% |
53.69%
3 pts worse
|
Numerator 36 · Denominator 71 |
| Discharge mobility score | 60.56% |
50.94%
9.6 pts better
|
Numerator 43 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 1.31% |
2.29%
1 pts better
|
Numerator 2 · Denominator 153 · Adjusted rate 0.91% |
| Healthcare-associated infections requiring hospitalization | 7.29% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 123 · Observed rate 13.01% · Lower 95% interval 4.74% |
| Staff COVID-19 vaccination coverage | 29.17% |
8.2%
21 pts better
|
Numerator 21 · Denominator 72 |
| Staff flu vaccination coverage | 72.84% |
42%
30.8 pts better
|
Numerator 118 · Denominator 162 |
| Discharge function score | 56.34% |
56.45%
0.1 pts worse
|
Numerator 40 · Denominator 71 |
| Transfer of health information to provider | 98.72% |
95.95%
2.8 pts better
|
Numerator 77 · Denominator 78 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.4% |
25.2%
3.2 pts better
|
Numerator 23 · Denominator 81 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.3
0.3 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 4.2 · Expected 4.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.2 · Expected 2.6 · 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 | 1.2% |
1.6%
0.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.2% · Q4 2.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
6.8%
3.3 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.9% · Q3 2.9% · Q4 4.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
4.1%
0.6 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 3.8% · Q4 7.1% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.4% |
13.7%
7.7 pts worse
|
19.6%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 20.3% · Q3 20.2% · Q4 21.1% · 4Q avg 21.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
14.2%
1.6 pts worse
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 19.1% · Q3 10.0% · Q4 13.8% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 7.0% |
0.4%
6.6 pts worse
|
0.1%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 9.9% · Q3 7.1% · Q4 6.7% · 4Q avg 7.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.4% |
11.0%
4.6 pts better
|
16.3%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 8.2% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
10.7%
1.8 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 4.2% · Q3 6.0% · Q4 13.0% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.8% |
1.0%
2.8 pts worse
|
1.0%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.8% · Q3 4.0% · Q4 2.7% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
1.2%
1.3 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.9% · Q3 1.2% · Q4 2.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.2% |
10.9%
8.7 pts better
|
19.8%
17.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 4.5% · Q4 2.8% · 4Q avg 2.2% |
| Percentage of long-stay residents with pressure ulcers | 14.4% |
4.7%
9.7 pts worse
|
5.1%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 12.5% · Q3 14.6% · Q4 17.1% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
94.0%
5.2 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 98.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.9% |
11.2%
7.3 pts better
|
12.0%
8.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.9% · Observed 4.6% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.6% |
93.2%
2.4 pts better
|
79.7%
15.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.8% |
23.2%
4.6 pts worse
|
23.9%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 37.4% · Expected 32.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-26 · Fire 2024-01-26
26 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
18 health deficiencies
Top issue: Pharmacy Service (6 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-02-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-02-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-13
F · Potential for more than minimal harm
2024-01-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-24
F · Potential for more than minimal harm
2024-01-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-26
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 2024-02-24
D · Potential for more than minimal harm
2024-01-26
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-24
C · Minimal harm
2024-01-26
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-02-24
C · Minimal harm
2024-01-26
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-02-24
E · Potential for more than minimal harm
2023-01-12
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 2023-01-26
D · Potential for more than minimal harm
2023-01-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-01-26
D · Potential for more than minimal harm
2023-01-12
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-01-26
D · Potential for more than minimal harm
2023-01-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-26
C · Minimal harm
2023-01-12
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-01-26
C · Minimal harm
2023-01-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-01-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-25
E · Potential for more than minimal harm
2025-05-28
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-28
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-02-21
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 2025-03-13
E · Potential for more than minimal harm
2025-02-21
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-21
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 2025-03-13
D · Potential for more than minimal harm
2025-02-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-21
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 2025-03-13
D · Potential for more than minimal harm
2025-02-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-21
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-21
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 2025-03-13
D · Potential for more than minimal harm
2025-02-21
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-13
B · Minimal harm
2025-02-21
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 2025-03-13
D · Potential for more than minimal harm
2025-02-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-02-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-19
D · Potential for more than minimal harm
2024-10-30
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 2024-11-20
D · Potential for more than minimal harm
2024-08-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-10
D · Potential for more than minimal harm
2024-04-25
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-05-25
E · Potential for more than minimal harm
2024-01-26
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 2024-02-25
E · Potential for more than minimal harm
2024-01-26
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 2024-02-25
E · Potential for more than minimal harm
2024-01-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-01-26
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 2024-02-25
E · Potential for more than minimal harm
2024-01-26
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-01-26
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 2024-02-25
E · Potential for more than minimal harm
2024-01-26
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 2024-02-25
D · Potential for more than minimal harm
2024-01-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-26
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-26
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-26
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-26
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-26
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 2024-02-25
D · Potential for more than minimal harm
2024-01-26
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 2024-02-25
D · Potential for more than minimal harm
2024-01-26
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 2024-02-25
D · Potential for more than minimal harm
2024-01-26
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-25
B · Minimal harm
2024-01-26
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 2024-02-25
D · Potential for more than minimal harm
2023-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-05
G · Actual harm
2023-08-18
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 2023-09-17
D · Potential for more than minimal harm
2023-04-04
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-04-14
G · Actual harm
2023-01-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-12
E · Potential for more than minimal harm
2023-01-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-02-08
E · Potential for more than minimal harm
2023-01-12
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 2023-02-08
D · Potential for more than minimal harm
2023-01-12
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 2023-02-12
D · Potential for more than minimal harm
2023-01-12
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-02-12
D · Potential for more than minimal harm
2023-01-12
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 2023-02-12
D · Potential for more than minimal harm
2023-01-12
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-02-12
D · Potential for more than minimal harm
2023-01-12
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-01-12
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 2023-02-08
D · Potential for more than minimal harm
2023-01-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-01-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-12
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 2023-02-08
D · Potential for more than minimal harm
2023-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-08
Penalties and ownership
What sits behind the stars
Ownership
Acsb LLC
5% Or Greater Direct Ownership Interest · Organization
Aspen Skilled Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Bradshaw, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Bradshaw, Jeffrey
Operational/Managerial Control · Individual
Bradshaw, Jeffrey
Corporate Director · Individual
Bradshaw, Jeffrey
Corporate Officer · Individual
Brady, Vern
5% Or Greater Indirect Ownership Interest · Individual
Brady, Vern
Operational/Managerial Control · Individual
Brady, Vern
Corporate Director · Individual
Brady, Vern
Corporate Officer · Individual
Case, Ryan
5% Or Greater Indirect Ownership Interest · Individual
Case, Ryan
Operational/Managerial Control · Individual
Case, Ryan
Corporate Director · Individual
Case, Ryan
Corporate Officer · Individual
Fortin, Wayne
Operational/Managerial Control · Individual
Kotula, Julie
Operational/Managerial Control · Individual
Kotula, Julie
W-2 Managing Employee · Individual
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5-star overall rating with 4-star inspections with 8 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#2
Vista Del Sol Care Center
Los Angeles, CA
2-star overall rating with 2-star inspections with $116,475 in total fines with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Meadowbrook Behavioral Health Center
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2-star overall rating with 1-star inspections with abuse icon flag with 19 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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