Cycle 1
Health 2025-07-03 · Fire 2025-07-03
21 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Montrose, CA
Montrose Springs Skilled Nursing & Wellness Center
3-star overall rating with 2-star inspections with abuse icon flag with $32,139 in total fines with 21 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2635 Honolulu Ave, Montrose, CA
(818) 248-6856
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
109
Certified beds
Average residents
120
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacific Healthcare Holdings
Operator or chain grouping
Approved since
1974-12-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 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
0.50
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.72
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,898
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.16
Composite VBP score used to determine payment impact.
Payment multiplier
1.0078
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.53
Baseline 16.46% · Performance 17.48% · Measure score 8.53 · Achievement 8.53 · Improvement 0
Healthcare-associated infections
2.53
Baseline 7.33% · Performance 7.08% · Measure score 2.53 · Achievement 2.53 · Improvement 0.59
Total nurse turnover
7.69
Baseline 43.68% · Performance 32.26% · Measure score 7.69 · Achievement 7.69 · Improvement 5.57
Adjusted total nurse staffing
2.51
Baseline 3.78 hours · Performance 3.79 hours · Measure score 2.51 · Achievement 2.51 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.9% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 172 · Observed rate 9.88% · Lower 95% interval 8.18% |
| Discharge to community | 54.74% |
50.57%
4.2 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 46.88% · Lower 95% interval 43.37% |
| Medicare spending per beneficiary | 1.65 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 113 · Denominator 113 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 113 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 54 · Denominator 81 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 36 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 2.65% |
2.29%
0.4 pts worse
|
Numerator 3 · Denominator 113 · Adjusted rate 1.89% |
| Healthcare-associated infections requiring hospitalization | 7.08% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 114 · Observed rate 7.02% · Lower 95% interval 4.31% |
| Staff COVID-19 vaccination coverage | 29.6% |
8.2%
21.4 pts better
|
Numerator 37 · Denominator 125 |
| Staff flu vaccination coverage | 78.03% |
42%
36 pts better
|
Numerator 103 · Denominator 132 |
| Discharge function score | 43.21% |
56.45%
13.2 pts worse
|
Numerator 35 · Denominator 81 |
| Transfer of health information to provider | 92.59% |
95.95%
3.4 pts worse
|
Numerator 25 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 100% |
25.2%
74.8 pts better
|
Numerator 66 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
2.3
0.9 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.7 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.6
1 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.7 · Expected 1.9 · 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 | 1.6% |
1.6%
About the same
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 1.9% · Q4 0.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 41.5% |
6.8%
34.7 pts worse
|
11.4%
30.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.1% · Q2 39.8% · Q3 34.0% · Q4 41.5% · 4Q avg 41.5% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
4.1%
1.5 pts worse
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 9.2% · Q3 3.1% · Q4 4.5% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
13.7%
1.5 pts worse
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 13.3% · Q3 16.7% · Q4 19.1% · 4Q avg 15.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.4% |
14.2%
16.2 pts worse
|
16.7%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 21.4% · Q3 34.0% · Q4 30.6% · 4Q avg 30.4% · 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 | 3.1% |
11.0%
7.9 pts better
|
16.3%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 7.8% · Q3 0.0% · Q4 2.4% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.2% |
10.7%
6.5 pts better
|
14.9%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 5.4% · Q3 2.2% · Q4 5.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.0%
0.1 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.3% · Q3 1.3% · Q4 0.9% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.2%
0.9 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 2.9% · Q4 3.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.3% |
10.9%
7.6 pts better
|
19.8%
16.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.9% · Q3 2.6% · Q4 1.0% · 4Q avg 3.3% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
4.7%
0.8 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 10.0% · Q3 2.3% · Q4 2.2% · 4Q avg 5.5% · 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 | 1.1% |
11.2%
10.1 pts better
|
12.0%
10.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 1.1% · Observed 1.0% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 1.8% · Q4 2.2% · 4Q avg 1.6% · 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 | 12.4% |
23.2%
10.8 pts better
|
23.9%
11.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 11.3% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-12 · Fire 2024-07-12
32 health deficiencies
Top issue: Resident Rights (8 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-03-24 · Fire 2022-03-24
27 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-07-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-25
D · Potential for more than minimal harm
2024-07-12
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 2024-08-12
D · Potential for more than minimal harm
2024-07-12
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-12
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 2024-08-12
E · Potential for more than minimal harm
2022-03-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-04-19
E · Potential for more than minimal harm
2022-03-24
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 2022-04-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-02-14
D · Potential for more than minimal harm
2026-01-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-02-14
E · Potential for more than minimal harm
2025-07-03
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 2025-07-25
D · Potential for more than minimal harm
2025-07-03
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 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
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 2025-07-25
D · Potential for more than minimal harm
2025-07-03
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 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
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 2025-07-25
D · Potential for more than minimal harm
2025-07-03
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 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-07-25
B · Minimal harm
2025-07-03
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 2025-07-25
B · Minimal harm
2025-07-03
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 2025-07-25
D · Potential for more than minimal harm
2025-05-01
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 2025-05-22
G · Actual harm
2025-03-28
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 2025-04-05
D · Potential for more than minimal harm
2025-03-28
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 2025-04-05
G · Actual harm
2025-03-12
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 2025-04-09
D · Potential for more than minimal harm
2025-02-20
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-03-14
E · Potential for more than minimal harm
2024-07-12
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-12
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 2024-08-05
E · Potential for more than minimal harm
2024-07-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-12
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 2024-08-05
E · Potential for more than minimal harm
2024-07-12
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 2024-08-05
E · Potential for more than minimal harm
2024-07-12
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 2024-08-05
D · Potential for more than minimal harm
2024-07-12
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 2024-08-05
D · Potential for more than minimal harm
2024-07-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-12
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 2024-08-05
D · Potential for more than minimal harm
2024-07-12
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-12
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 2024-08-05
D · Potential for more than minimal harm
2024-07-12
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 2024-08-05
D · Potential for more than minimal harm
2024-07-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-12
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 2024-08-05
D · Potential for more than minimal harm
2024-07-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-12
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-12
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-08-05
B · Minimal harm
2024-07-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-08-05
B · Minimal harm
2024-07-12
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 2024-08-05
B · Minimal harm
2024-07-12
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 2024-08-05
D · Potential for more than minimal harm
2024-05-17
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 2024-06-14
D · Potential for more than minimal harm
2024-05-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-14
G · Actual harm
2024-05-10
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-05-10
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 2024-06-03
D · Potential for more than minimal harm
2024-04-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-09
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-09
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 2024-04-29
D · Potential for more than minimal harm
2024-03-06
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 2024-03-22
D · Potential for more than minimal harm
2024-03-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-27
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
D · Potential for more than minimal harm
2023-11-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-26
D · Potential for more than minimal harm
2023-06-13
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 2023-06-29
D · Potential for more than minimal harm
2023-06-07
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 2023-06-15
D · Potential for more than minimal harm
2023-06-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-06-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-06-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-06-28
D · Potential for more than minimal harm
2023-06-02
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-06-28
E · Potential for more than minimal harm
2022-03-24
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 2022-04-26
D · Potential for more than minimal harm
2022-03-24
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 2022-04-26
D · Potential for more than minimal harm
2022-03-24
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 2022-04-26
D · Potential for more than minimal harm
2022-03-24
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-04-26
D · Potential for more than minimal harm
2022-03-24
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 2022-04-26
D · Potential for more than minimal harm
2022-03-24
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 2022-04-26
D · Potential for more than minimal harm
2022-03-24
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 2022-04-26
D · Potential for more than minimal harm
2022-03-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-04-26
D · Potential for more than minimal harm
2022-03-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-04-26
D · Potential for more than minimal harm
2022-03-24
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 2022-04-26
D · Potential for more than minimal harm
2022-03-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-04-26
D · Potential for more than minimal harm
2022-03-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-04-26
D · Potential for more than minimal harm
2022-03-24
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 2022-04-26
D · Potential for more than minimal harm
2022-03-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-04-26
D · Potential for more than minimal harm
2022-03-24
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 2022-04-26
D · Potential for more than minimal harm
2022-03-24
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 2022-04-26
D · Potential for more than minimal harm
2022-03-24
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-04-26
B · Minimal harm
2022-03-24
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 2022-04-26
B · Minimal harm
2022-03-24
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 2022-04-26
Penalties and ownership
What sits behind the stars
$32,139
2025-02-20
Fine
Fine · fine $32,139
Fine
$0
2024-05-10
Payment Denial
Payment Denial · denial start 2024-06-08 · 6 days
6 day denial
Ownership
Pacific Healthcare Holdings, Inc.
5% Or Greater Direct Ownership Interest · Organization
Blonder, David
5% Or Greater Direct Ownership Interest · Individual
Aghajanyan, Ani
Operational/Managerial Control · Individual
Corporate Interface Services LLC
Operational/Managerial Control · Organization
Karakashian, Garo
Operational/Managerial Control · Individual
Rechnitz, Shlomo
Operational/Managerial Control · Individual
Rechnitz, Shlomo
Corporate Officer · Individual
Rockport Administrative Services, LLC
Operational/Managerial Control · Organization
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