Cycle 1
Health 2025-05-30 · Fire 2025-05-30
17 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Palo Alto, CA
Palo Alto Sub-Acute And Rehabilitation Center
3-star overall rating with 3-star inspections with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
911 Bryant Street, Palo Alto, CA
(650) 327-0511
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
60
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Covenant Care
Operator or chain grouping
Approved since
1971-10-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
24 facilities
Chain averages 3 overall / 3 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
1.21
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.23
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.15
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.67
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.87
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.17
CMS adjusted RN staffing hours
Adjusted total hours
4.12
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,061
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9995
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.28
Baseline 20.96% · Performance 19.91% · Measure score 3.28 · Achievement 3.28 · Improvement 2.17
Healthcare-associated infections
6.62
Baseline 5.06% · Performance 5.86% · Measure score 6.62 · Achievement 6.62 · Improvement 0
Total nurse turnover
5.30
Baseline 57.89% · Performance 42.03% · Measure score 5.30 · Achievement 5.30 · Improvement 4.30
Adjusted total nurse staffing
3.29
Baseline 3.97 hours · Performance 4.01 hours · Measure score 3.29 · Achievement 3.29 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.49% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 374 · Observed rate 12.03% · Lower 95% interval 8.73% |
| Discharge to community | 66.49% |
50.57%
15.9 pts better
|
Better than the National Rate · Eligible stays 380 · Observed rate 57.63% · Lower 95% interval 60.84% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.65% |
95.27%
4.4 pts better
|
Numerator 286 · Denominator 287 |
| Falls with major injury | 0.35% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 287 |
| Discharge self-care score | 53.28% |
53.69%
0.4 pts worse
|
Numerator 65 · Denominator 122 |
| Discharge mobility score | 65.57% |
50.94%
14.6 pts better
|
Numerator 80 · Denominator 122 |
| Pressure ulcers or injuries, new or worsened | 0.35% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 287 · Adjusted rate 0.36% |
| Healthcare-associated infections requiring hospitalization | 5.86% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 238 · Observed rate 5.88% · Lower 95% interval 3.96% |
| Staff COVID-19 vaccination coverage | 10.83% |
8.2%
2.6 pts better
|
Numerator 13 · Denominator 120 |
| Staff flu vaccination coverage | 45.63% |
42%
3.6 pts better
|
Numerator 73 · Denominator 160 |
| Discharge function score | 59.02% |
56.45%
2.6 pts better
|
Numerator 72 · Denominator 122 |
| Transfer of health information to provider | 99.42% |
95.95%
3.5 pts better
|
Numerator 172 · Denominator 173 |
| Transfer of health information to patient | 97.83% |
96.28%
1.5 pts better
|
Numerator 90 · Denominator 92 |
| Resident COVID-19 vaccinations up to date | 39.1% |
25.2%
13.9 pts better
|
Numerator 61 · Denominator 156 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
1.6%
0.6 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 29.2% |
6.8%
22.4 pts worse
|
11.4%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 36.4% · Q3 29.2% · Q4 26.9% · 4Q avg 29.2% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 17.5% |
13.7%
3.8 pts worse
|
19.6%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 16.7% · Q3 20.0% · Q4 16.0% · 4Q avg 17.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
14.2%
4.8 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.4% · 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 need for help with daily activities has increased | 9.1% |
10.7%
1.6 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 13.6% · Q3 8.7% · Q4 0.0% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.5% |
1.0%
3.5 pts worse
|
1.0%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 15.8% |
10.9%
4.9 pts worse
|
19.8%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.8% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.7%
2.7 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
94.0%
5.8 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 99.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.5% |
11.2%
2.3 pts worse
|
12.0%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 14.5% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.7% |
93.2%
3.5 pts better
|
79.7%
17 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
23.2%
5.2 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 29.0% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-26 · Fire 2024-02-26
11 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-04-08 · Fire 2022-04-08
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-05-30
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-05-30
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 2025-06-04
D · Potential for more than minimal harm
2025-05-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-05-30
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-07-07
F · Potential for more than minimal harm
2024-02-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-02-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-26
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-26
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-26
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 2024-02-28
D · Potential for more than minimal harm
2024-02-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-26
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-28
F · Potential for more than minimal harm
2022-04-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-04-28
E · Potential for more than minimal harm
2022-04-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-28
E · Potential for more than minimal harm
2022-04-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-04-28
E · Potential for more than minimal harm
2022-04-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-04-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-04-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-04-08
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-04-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-04-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-04-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-04-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-04-08
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 2022-04-28
D · Potential for more than minimal harm
2022-04-08
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-04-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-04-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-04-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-04-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-04-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-30
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-05-30
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 2025-06-30
E · Potential for more than minimal harm
2025-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-30
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-30
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 2025-06-30
D · Potential for more than minimal harm
2025-05-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-30
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-30
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 2025-06-30
D · Potential for more than minimal harm
2025-05-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-30
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-30
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 2025-06-30
D · Potential for more than minimal harm
2025-05-30
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 2025-06-30
D · Potential for more than minimal harm
2025-05-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-30
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 2025-06-30
B · Minimal harm
2025-05-30
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.
Not marked corrected
F · Potential for more than minimal harm
2024-02-26
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 2024-03-26
F · Potential for more than minimal harm
2024-02-26
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-03-26
E · Potential for more than minimal harm
2024-02-26
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 2024-03-26
E · Potential for more than minimal harm
2024-02-26
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-03-26
E · Potential for more than minimal harm
2024-02-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-26
D · Potential for more than minimal harm
2024-02-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-26
D · Potential for more than minimal harm
2024-02-26
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 2024-03-26
D · Potential for more than minimal harm
2024-02-26
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 2024-03-26
D · Potential for more than minimal harm
2024-02-26
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 2024-03-26
D · Potential for more than minimal harm
2024-02-26
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-03-26
B · Minimal harm
2024-02-26
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.
Not marked corrected
D · Potential for more than minimal harm
2024-01-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-02
E · Potential for more than minimal harm
2022-04-08
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 2022-05-08
E · Potential for more than minimal harm
2022-04-08
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 2022-05-08
E · Potential for more than minimal harm
2022-04-08
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 2022-05-08
E · Potential for more than minimal harm
2022-04-08
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 2022-05-08
E · Potential for more than minimal harm
2022-04-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-04-08
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-04-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-08
D · Potential for more than minimal harm
2022-04-08
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 2022-05-08
D · Potential for more than minimal harm
2022-04-08
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 2022-05-08
Penalties and ownership
What sits behind the stars
Ownership
Ashley, Dava
Operational/Managerial Control · Individual
Ashley, Dava
Corporate Officer · Individual
Carney, Kevin
Corporate Officer · Individual
Centre Capital Investors V, LP
5% Or Greater Indirect Ownership Interest · Organization
Centre Covenant Purchaser (B), LLC
5% Or Greater Indirect Ownership Interest · Organization
Centre Covenant Purchaser (Q), LLC
5% Or Greater Indirect Ownership Interest · Organization
Centre Covenant Purchaser (S), LLC
5% Or Greater Indirect Ownership Interest · Organization
Centre V Secondary Fund, L.p.
5% Or Greater Indirect Ownership Interest · Organization
Covenant Care California, LLC
5% Or Greater Direct Ownership Interest · Organization
Covenant Care California, LLC
Operational/Managerial Control · Organization
Covenant Care, LLC
5% Or Greater Direct Ownership Interest · Organization
Covenant Holdco, LLC
5% Or Greater Indirect Ownership Interest · Organization
Covenant Subco, LLC
5% Or Greater Indirect Ownership Interest · Organization
Evans, Mary
5% Or Greater Indirect Ownership Interest · Individual
Evans, Mary
Operational/Managerial Control · Individual
Evans, Mary
Corporate Officer · Individual
Hassell, Lance
Operational/Managerial Control · Individual
Hassell, Lance
Corporate Officer · Individual
Levin, Robert
5% Or Greater Indirect Ownership Interest · Individual
Levin, Robert
Operational/Managerial Control · Individual
Levin, Robert
Corporate Officer · Individual
Midcap Funding Iv Trust
5% Or Greater Security Interest · Organization
Sims, Christine
5% Or Greater Indirect Ownership Interest · Individual
Sims, Christine
Operational/Managerial Control · Individual
Sims, Christine
Corporate Officer · Individual
Sparks, Carol
Operational/Managerial Control · Individual
State Treasurer Of Mich Custodian Of Public School Empl Rtmnt Systems
5% Or Greater Indirect Ownership Interest · Organization
Stockwell Fund Ii LP
5% Or Greater Indirect Ownership Interest · Organization
Torok, Andrew
5% Or Greater Indirect Ownership Interest · Individual
Torok, Andrew
Corporate Officer · Individual
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5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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5-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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4-star overall rating with 3-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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