Cycle 1
Health 2025-02-27 · Fire 2025-02-27
31 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
El Cajon, CA
San Diego Post-Acute Center
1-star overall rating with 1-star inspections with abuse icon flag with $11,213 in total fines with 31 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1201 South Orange Ave., El Cajon, CA
(619) 441-1988
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
240
Certified beds
Average residents
234
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1996-03-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
0.56
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.67
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.41
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.96
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,389
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.58
Baseline 18.94% · Performance 18.85% · Measure score 5.58 · Achievement 5.58 · Improvement 0
Healthcare-associated infections
0
Baseline 8.91% · Performance 9.36% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.38
Performance 45.78% · Measure score 4.38 · Achievement 4.38 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.82
Baseline 2.96 hours · Performance 3.31 hours · Measure score 0.82 · Achievement 0.82 · Improvement 0.75
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.38% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 297 · Observed rate 7.41% · Lower 95% interval 7.07% |
| Discharge to community | 51.2% |
50.57%
0.6 pts better
|
No Different than the National Rate · Eligible stays 237 · Observed rate 38.82% · Lower 95% interval 43.69% |
| Medicare spending per beneficiary | 1.67 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 404 · Denominator 404 |
| Falls with major injury | 0.74% |
0.77%
About the same
|
Numerator 3 · Denominator 404 |
| Discharge self-care score | 47.33% |
53.69%
6.4 pts worse
|
Numerator 124 · Denominator 262 |
| Discharge mobility score | 49.62% |
50.94%
1.3 pts worse
|
Numerator 130 · Denominator 262 |
| Pressure ulcers or injuries, new or worsened | 0.5% |
2.29%
1.8 pts better
|
Numerator 2 · Denominator 404 · Adjusted rate 0.6% |
| Healthcare-associated infections requiring hospitalization | 9.36% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 274 · Observed rate 9.85% · Lower 95% interval 6.73% |
| Staff COVID-19 vaccination coverage | 0.47% |
8.2%
7.7 pts worse
|
Numerator 2 · Denominator 428 |
| Staff flu vaccination coverage | 44.74% |
42%
2.7 pts better
|
Numerator 200 · Denominator 447 |
| Discharge function score | 55.73% |
56.45%
0.7 pts worse
|
Numerator 146 · Denominator 262 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 157 · Denominator 157 |
| Transfer of health information to patient | 93.75% |
96.28%
2.5 pts worse
|
Numerator 60 · Denominator 64 |
| Resident COVID-19 vaccinations up to date | 31.6% |
25.2%
6.4 pts better
|
Numerator 73 · Denominator 231 |
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 2.9 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.2 · Expected 2.0 · 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 | 99.6% |
98.2%
1.4 pts better
|
95.5%
4.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
1.6%
1.2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.9% |
6.8%
4.1 pts worse
|
11.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 12.1% · Q3 9.8% · Q4 10.8% · 4Q avg 10.9% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
4.1%
2.9 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 1.1% · Q4 3.1% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.1% |
13.7%
4.4 pts worse
|
19.6%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 17.8% · Q3 15.7% · Q4 18.8% · 4Q avg 18.1% |
| 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 | 4.6% |
11.0%
6.4 pts better
|
16.3%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 1.5% · Q3 2.6% · Q4 3.6% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.8% |
10.7%
1.9 pts better
|
14.9%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 7.0% · Q3 6.5% · Q4 11.4% · 4Q avg 8.8% · 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 | 0.0% |
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 | 5.4% |
10.9%
5.5 pts better
|
19.8%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 1.2% · Q3 3.6% · Q4 5.7% · 4Q avg 5.4% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.7%
0.9 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 3.7% · Q3 4.9% · Q4 2.2% · 4Q avg 3.8% · 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 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.2% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
11.2%
1.6 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 10.2% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.8% |
1.5%
4.3 pts worse
|
1.6%
4.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 8.1% · Q3 8.8% · Q4 0.0% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.2% |
93.2%
2 pts better
|
79.7%
15.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| 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 18.1% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-16 · Fire 2022-06-16
21 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-05-23 · Fire 2019-05-23
41 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-27
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-27
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-27
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 2025-03-24
C · Minimal harm
2025-02-27
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-03-24
C · Minimal harm
2025-02-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-24
C · Minimal harm
2025-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-24
D · Potential for more than minimal harm
2022-06-16
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-16
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-16
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-16
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-14
E · Potential for more than minimal harm
2019-05-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-07-10
E · Potential for more than minimal harm
2019-05-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-07-10
D · Potential for more than minimal harm
2019-05-23
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2019-07-10
D · Potential for more than minimal harm
2019-05-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-07-10
D · Potential for more than minimal harm
2019-05-23
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 2019-07-10
D · Potential for more than minimal harm
2019-05-23
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 2019-07-10
D · Potential for more than minimal harm
2019-05-23
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2019-07-10
D · Potential for more than minimal harm
2019-05-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-07-10
D · Potential for more than minimal harm
2019-05-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-07-10
Inspection history
Recent health citations
G · Actual harm
2026-01-23
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-23
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Not marked corrected
D · Potential for more than minimal harm
2026-01-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Not marked corrected
D · Potential for more than minimal harm
2026-01-23
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Not marked corrected
D · Potential for more than minimal harm
2026-01-23
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Not marked corrected
D · Potential for more than minimal harm
2026-01-23
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.
Not marked corrected
D · Potential for more than minimal harm
2025-12-02
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 2025-12-12
D · Potential for more than minimal harm
2025-12-02
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 2025-12-12
D · Potential for more than minimal harm
2025-09-18
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 2025-09-30
D · Potential for more than minimal harm
2025-07-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Not marked corrected
D · Potential for more than minimal harm
2025-07-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
D · Potential for more than minimal harm
2025-06-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-27
F · Potential for more than minimal harm
2025-05-15
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 2025-06-09
F · Potential for more than minimal harm
2025-05-15
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-03-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-02-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-02-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-02-27
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 2025-03-27
E · Potential for more than minimal harm
2025-02-27
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
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 2025-03-27
D · Potential for more than minimal harm
2025-02-27
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 2025-03-27
D · Potential for more than minimal harm
2025-02-27
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 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
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 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-01-24
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 2025-02-14
D · Potential for more than minimal harm
2024-09-05
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-10-04
G · Actual harm
2024-07-17
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 2024-07-31
D · Potential for more than minimal harm
2024-07-17
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 2024-07-31
D · Potential for more than minimal harm
2024-05-28
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-05-01
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 2024-05-31
D · Potential for more than minimal harm
2024-02-20
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 2024-03-12
D · Potential for more than minimal harm
2024-02-09
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 2024-02-22
D · Potential for more than minimal harm
2023-12-28
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 2024-01-15
D · Potential for more than minimal harm
2023-12-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-10-30
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 2023-11-10
D · Potential for more than minimal harm
2023-10-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-10-05
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-10-05
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 2023-10-23
D · Potential for more than minimal harm
2023-08-28
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 2023-09-11
E · Potential for more than minimal harm
2023-08-10
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 2023-09-07
D · Potential for more than minimal harm
2023-08-10
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 2023-09-07
D · Potential for more than minimal harm
2023-08-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-10
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 2023-09-07
D · Potential for more than minimal harm
2023-08-10
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-06-30
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-27
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 2023-07-12
D · Potential for more than minimal harm
2023-03-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-16
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 2023-04-07
D · Potential for more than minimal harm
2023-03-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-07
G · Actual harm
2023-03-14
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 2023-04-14
D · Potential for more than minimal harm
2023-03-14
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 2023-04-14
D · Potential for more than minimal harm
2023-03-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-14
E · Potential for more than minimal harm
2022-06-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-23
D · Potential for more than minimal harm
2022-06-16
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 2022-08-23
D · Potential for more than minimal harm
2022-06-16
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 2022-08-23
D · Potential for more than minimal harm
2022-06-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-23
D · Potential for more than minimal harm
2022-06-16
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-08-23
D · Potential for more than minimal harm
2022-06-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-23
D · Potential for more than minimal harm
2022-06-16
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 2022-08-23
D · Potential for more than minimal harm
2022-06-16
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 2022-08-23
D · Potential for more than minimal harm
2022-06-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-23
D · Potential for more than minimal harm
2022-06-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-08-23
D · Potential for more than minimal harm
2022-06-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-08-23
D · Potential for more than minimal harm
2022-06-16
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 2022-08-23
D · Potential for more than minimal harm
2022-06-16
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 2022-08-23
D · Potential for more than minimal harm
2022-06-16
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-08-23
D · Potential for more than minimal harm
2022-06-16
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-08-23
E · Potential for more than minimal harm
2019-05-23
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2019-06-23
E · Potential for more than minimal harm
2019-05-23
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 2019-06-23
D · Potential for more than minimal harm
2019-05-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-06-23
D · Potential for more than minimal harm
2019-05-23
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 2019-06-23
D · Potential for more than minimal harm
2019-05-23
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 2019-06-23
D · Potential for more than minimal harm
2019-05-23
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 2019-06-23
D · Potential for more than minimal harm
2019-05-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-06-23
D · Potential for more than minimal harm
2019-05-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-06-23
D · Potential for more than minimal harm
2019-05-23
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 2019-06-23
D · Potential for more than minimal harm
2019-05-23
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 2019-06-23
D · Potential for more than minimal harm
2019-05-23
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-06-23
D · Potential for more than minimal harm
2019-05-23
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-06-23
D · Potential for more than minimal harm
2019-05-23
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 2019-06-23
D · Potential for more than minimal harm
2019-05-23
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 2019-06-23
D · Potential for more than minimal harm
2019-05-23
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2019-06-23
D · Potential for more than minimal harm
2019-05-23
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 2019-06-23
D · Potential for more than minimal harm
2019-05-23
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2019-06-23
Penalties and ownership
What sits behind the stars
$11,213
2024-07-17
Fine
Fine · fine $11,213
Fine
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jenkins, William
W-2 Managing Employee · Individual
Jergensen, Joshua
Corporate Officer · Individual
Michlin, Bernard
Contracted Managing Employee · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
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