Cycle 1
Health 2025-08-19 · Fire 2025-08-19
39 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Newport Beach, CA
Pelican Ridge Post Acute
2-star overall rating with 2-star inspections with 39 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
466 Flagship Road, Newport Beach, CA
(949) 642-8044
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
167
Certified beds
Average residents
143
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David & Frank Johnson
Operator or chain grouping
Approved since
1978-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
45 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
0.38
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.90
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.28
CMS adjusted total nurse staffing hours
Case-mix index
1.63
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,600
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9892
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.66
Baseline 22.99% · Performance 19.32% · Measure score 5.66 · Achievement 4.56 · Improvement 5.66
Healthcare-associated infections
3.60
Baseline 11.36% · Performance 8.75% · Measure score 3.60 · Achievement 0 · Improvement 3.60
Total nurse turnover
3.75
Baseline 53.49% · Performance 48.34% · Measure score 3.75 · Achievement 3.75 · Improvement 1.30
Adjusted total nurse staffing
1.22
Baseline 3.10 hours · Performance 3.42 hours · Measure score 1.22 · Achievement 1.22 · Improvement 0.71
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.01% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 243 · Observed rate 13.17% · Lower 95% interval 8.65% |
| Discharge to community | 45.95% |
50.57%
4.6 pts worse
|
No Different than the National Rate · Eligible stays 250 · Observed rate 37.6% · Lower 95% interval 40.24% |
| Medicare spending per beneficiary | 1.3 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 96.47% |
95.27%
1.2 pts better
|
Numerator 246 · Denominator 255 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 255 |
| Discharge self-care score | 57.97% |
53.69%
4.3 pts better
|
Numerator 40 · Denominator 69 |
| Discharge mobility score | 55.07% |
50.94%
4.1 pts better
|
Numerator 38 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 1.96% |
2.29%
0.3 pts better
|
Numerator 5 · Denominator 255 · Adjusted rate 1.58% |
| Healthcare-associated infections requiring hospitalization | 8.75% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 195 · Observed rate 10.77% · Lower 95% interval 6.62% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 220 |
| Staff flu vaccination coverage | 27.45% |
42%
14.6 pts worse
|
Numerator 56 · Denominator 204 |
| Discharge function score | 57.97% |
56.45%
1.5 pts better
|
Numerator 40 · Denominator 69 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 180 · Denominator 180 |
| Transfer of health information to patient | 91.67% |
96.28%
4.6 pts worse
|
Numerator 33 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 14.62% |
25.2%
10.6 pts worse
|
Numerator 19 · Denominator 130 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.6 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
98.5%
1 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 99.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
98.2%
0.8 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 8.1% |
6.8%
1.3 pts worse
|
11.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 6.3% · Q3 7.1% · Q4 11.0% · 4Q avg 8.1% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
4.1%
0.1 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.6% · Q3 4.7% · Q4 2.4% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.7% |
13.7%
6 pts better
|
19.6%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 6.2% · Q3 4.6% · Q4 9.3% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.4% |
14.2%
8.8 pts better
|
16.7%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 9.6% · Q3 3.5% · Q4 1.6% · 4Q avg 5.4% · 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 | 9.7% |
11.0%
1.3 pts better
|
16.3%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 8.1% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.7% |
10.7%
5 pts better
|
14.9%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 1.5% · Q3 1.3% · Q4 10.1% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.2%
0.7 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.0% |
10.9%
1.9 pts better
|
19.8%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 10.9% · Q3 5.8% · Q4 3.5% · 4Q avg 9.0% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.7%
0.2 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 4.8% · Q3 3.1% · Q4 2.1% · 4Q avg 4.9% · 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 99.4% · Q2 98.4% · Q3 99.2% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
11.2%
0.7 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 12.1% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.9% · Q3 0.4% · Q4 1.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.9% |
93.2%
1.3 pts worse
|
79.7%
12.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.3% |
23.2%
1.9 pts better
|
23.9%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 22.6% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-19 · Fire 2024-07-19
33 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-07-12 · Fire 2022-07-12
17 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-08-19
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-08-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-19
C · Minimal harm
2025-08-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-19
C · Minimal harm
2025-08-19
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 2025-09-19
F · Potential for more than minimal harm
2024-07-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-07-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-07-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-07-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-07-19
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-19
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
2024-07-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-19
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-08-12
C · Minimal harm
2024-07-19
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-08-12
C · Minimal harm
2024-07-19
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-08-12
C · Minimal harm
2024-07-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-12
E · Potential for more than minimal harm
2022-07-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-08-05
E · Potential for more than minimal harm
2022-07-12
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-08-05
E · Potential for more than minimal harm
2022-07-12
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-08-05
E · Potential for more than minimal harm
2022-07-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-05
D · Potential for more than minimal harm
2022-07-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-08-05
D · Potential for more than minimal harm
2022-07-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-05
D · Potential for more than minimal harm
2022-07-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-05
D · Potential for more than minimal harm
2022-07-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-08-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-06
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-11-05
D · Potential for more than minimal harm
2025-10-06
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 2025-11-05
D · Potential for more than minimal harm
2025-10-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-05
B · Minimal harm
2025-10-06
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 2025-11-05
B · Minimal harm
2025-10-06
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-11-05
D · Potential for more than minimal harm
2025-09-25
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 2025-10-25
D · Potential for more than minimal harm
2025-09-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-09-25
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 2025-10-25
D · Potential for more than minimal harm
2025-09-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-09-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-09-25
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 2025-10-25
D · Potential for more than minimal harm
2025-09-25
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 2025-10-25
B · Minimal harm
2025-09-25
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 2025-10-25
B · Minimal harm
2025-09-25
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 2025-10-25
B · Minimal harm
2025-09-25
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 2025-10-25
D · Potential for more than minimal harm
2025-08-19
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
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 2025-09-18
D · Potential for more than minimal harm
2025-08-19
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 2025-09-18
D · Potential for more than minimal harm
2025-08-19
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 2025-09-18
D · Potential for more than minimal harm
2025-08-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-19
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 2025-09-18
D · Potential for more than minimal harm
2025-08-19
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 2025-09-18
D · Potential for more than minimal harm
2025-08-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-18
B · Minimal harm
2025-08-19
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 2025-09-18
B · Minimal harm
2025-08-19
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-09-18
B · Minimal harm
2025-08-19
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 2025-09-18
B · Minimal harm
2025-07-09
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 2025-08-08
B · Minimal harm
2025-07-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-04-18
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 2025-05-18
D · Potential for more than minimal harm
2025-04-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-18
B · Minimal harm
2025-02-18
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 2025-03-20
D · Potential for more than minimal harm
2025-01-29
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 2025-02-28
D · Potential for more than minimal harm
2024-12-12
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 2025-01-12
E · Potential for more than minimal harm
2024-07-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-19
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 2024-08-19
E · Potential for more than minimal harm
2024-07-19
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-19
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-19
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 2024-08-19
D · Potential for more than minimal harm
2024-07-19
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 2024-08-19
D · Potential for more than minimal harm
2024-07-19
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 2024-08-19
D · Potential for more than minimal harm
2024-07-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-19
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-19
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 2024-08-19
D · Potential for more than minimal harm
2024-07-19
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-19
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 2024-08-19
D · Potential for more than minimal harm
2024-07-19
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-19
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-08-19
B · Minimal harm
2024-07-19
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 2024-08-19
B · Minimal harm
2024-07-19
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-08-19
B · Minimal harm
2024-07-19
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-05-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-06
D · Potential for more than minimal harm
2024-03-19
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 2024-04-18
B · Minimal harm
2024-03-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-04
B · Minimal harm
2023-10-04
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 2023-11-03
D · Potential for more than minimal harm
2023-08-23
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 2023-09-22
B · Minimal harm
2023-08-23
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 2023-09-22
D · Potential for more than minimal harm
2023-03-28
F564 · Resident Rights Deficiencies
Health
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
Corrected 2023-05-01
E · Potential for more than minimal harm
2022-07-12
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 2022-08-11
D · Potential for more than minimal harm
2022-07-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-08-11
D · Potential for more than minimal harm
2022-07-12
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-08-11
D · Potential for more than minimal harm
2022-07-12
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 2022-08-11
D · Potential for more than minimal harm
2022-07-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-08-11
D · Potential for more than minimal harm
2022-07-12
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-08-11
D · Potential for more than minimal harm
2022-07-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-08-11
D · Potential for more than minimal harm
2022-07-12
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 2022-08-11
D · Potential for more than minimal harm
2022-07-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-08-11
D · Potential for more than minimal harm
2022-07-12
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 2022-08-11
D · Potential for more than minimal harm
2022-07-12
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 2022-08-11
D · Potential for more than minimal harm
2022-07-12
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 2022-08-11
D · Potential for more than minimal harm
2022-07-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-11
Penalties and ownership
What sits behind the stars
Ownership
Dehghanmanesh, Adrian
Corporate Officer · Individual
Flagship Post Acute LLC
5% Or Greater Direct Ownership Interest · Organization
Johnson, David
5% Or Greater Direct Ownership Interest · Individual
Johnson, Frank
5% Or Greater Direct Ownership Interest · Individual
Koontz, Robert
W-2 Managing Employee · Individual
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#3
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