Cycle 1
Health 2025-05-02 · Fire 2025-05-02
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Vista, CA
Santa Fe Post-Acute
1-star overall rating with 2-star inspections with $85,943 in total fines with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
247 E. Bobier Drive, Vista, CA
(760) 945-3033
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
187
Certified beds
Average residents
178
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bayshire Senior Communities
Operator or chain grouping
Approved since
1998-04-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
8,071
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9848
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.76
Baseline 20.27% · Performance 19.23% · Measure score 4.76 · Achievement 4.76 · Improvement 2.73
Healthcare-associated infections
3.07
Baseline 6.31% · Performance 6.92% · Measure score 3.07 · Achievement 3.07 · Improvement 0
Total nurse turnover
0
Baseline 64.23% · Performance 65.41% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.33
Baseline 3.93 hours · Performance 4.02 hours · Measure score 3.33 · Achievement 3.33 · Improvement 0.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.4% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 9.88% · Lower 95% interval 6.32% |
| Discharge to community | 36.14% |
50.57%
14.4 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 23.91% · Lower 95% interval 24.5% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.91% |
95.27%
3.6 pts better
|
Numerator 91 · Denominator 92 |
| Falls with major injury | 1.09% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 92 |
| Discharge self-care score | 61.29% |
53.69%
7.6 pts better
|
Numerator 38 · Denominator 62 |
| Discharge mobility score | 64.52% |
50.94%
13.6 pts better
|
Numerator 40 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 2.17% |
2.29%
0.1 pts better
|
Numerator 2 · Denominator 92 · Adjusted rate 1.97% |
| Healthcare-associated infections requiring hospitalization | 6.92% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 6.56% · Lower 95% interval 3.24% |
| Staff COVID-19 vaccination coverage | 5.68% |
8.2%
2.5 pts worse
|
Numerator 20 · Denominator 352 |
| Staff flu vaccination coverage | 91.47% |
42%
49.5 pts better
|
Numerator 268 · Denominator 293 |
| Discharge function score | 67.74% |
56.45%
11.3 pts better
|
Numerator 42 · Denominator 62 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 24.49% |
25.2%
0.7 pts worse
|
Numerator 12 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.3
1.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.6
0.7 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
98.5%
3 pts worse
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 96.5% · Q3 94.7% · Q4 95.9% · 4Q avg 95.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.5% |
98.2%
4.7 pts worse
|
95.5%
2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
1.6%
2.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.6% · Q3 4.7% · Q4 2.9% · 4Q avg 4.2% · 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 3.9% · Q2 8.7% · Q3 17.6% · Q4 1.4% · 4Q avg 8.1% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
4.1%
0.7 pts worse
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.8% · Q3 5.9% · Q4 6.5% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.7% |
13.7%
18 pts worse
|
19.6%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 32.5% · Q3 34.2% · Q4 29.7% · 4Q avg 31.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.9% |
14.2%
7.7 pts worse
|
16.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 23.1% · Q3 21.0% · Q4 17.1% · 4Q avg 21.9% · 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 | 11.7% |
11.0%
0.7 pts worse
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 10.4% · Q3 7.7% · Q4 12.3% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.1% |
10.7%
2.6 pts better
|
14.9%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 9.5% · Q3 5.0% · Q4 9.7% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.2%
0.6 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.2% · Q3 0.0% · Q4 0.6% · 4Q avg 0.6% · 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 · Q1 14.5% · Q2 19.6% · Q3 12.3% · Q4 17.0% · 4Q avg 15.8% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
4.7%
0.9 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 8.1% · Q3 4.8% · Q4 2.7% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.2% |
94.0%
16.8 pts worse
|
81.7%
4.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.4% · Q2 78.4% · Q3 77.0% · Q4 77.1% · 4Q avg 77.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.3% |
11.2%
6.1 pts worse
|
12.0%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 18.8% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.8% |
93.2%
13.4 pts worse
|
79.7%
0.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
23.2%
1.5 pts worse
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 25.0% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-14 · Fire 2022-07-14
18 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-02-07 · Fire 2019-02-07
21 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-28
E · Potential for more than minimal harm
2025-05-02
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 2025-05-28
E · Potential for more than minimal harm
2025-05-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-28
C · Minimal harm
2025-05-02
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-05-28
C · Minimal harm
2025-05-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-05-28
F · Potential for more than minimal harm
2023-08-02
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-09-14
E · Potential for more than minimal harm
2022-07-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-08
E · Potential for more than minimal harm
2022-07-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-08
D · Potential for more than minimal harm
2022-07-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-08
D · Potential for more than minimal harm
2022-07-14
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 2022-08-08
D · Potential for more than minimal harm
2022-07-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-08
D · Potential for more than minimal harm
2022-07-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-08-08
E · Potential for more than minimal harm
2019-02-07
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-04-19
E · Potential for more than minimal harm
2019-02-07
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2019-04-19
E · Potential for more than minimal harm
2019-02-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-04-19
E · Potential for more than minimal harm
2019-02-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-04-19
D · Potential for more than minimal harm
2019-02-07
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2019-04-19
D · Potential for more than minimal harm
2019-02-07
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 2019-04-19
D · Potential for more than minimal harm
2019-02-07
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-04-19
D · Potential for more than minimal harm
2019-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-19
D · Potential for more than minimal harm
2019-02-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-04-19
D · Potential for more than minimal harm
2019-02-07
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2019-04-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-04
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 2025-10-15
D · Potential for more than minimal harm
2025-05-19
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-05-02
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 2025-06-02
D · Potential for more than minimal harm
2025-05-02
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-02
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 2025-06-02
D · Potential for more than minimal harm
2025-05-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-02
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 2025-06-02
D · Potential for more than minimal harm
2025-05-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-02-06
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-03-06
D · Potential for more than minimal harm
2024-05-31
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 2024-07-01
K · Immediate jeopardy
2023-09-21
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2023-11-06
G · Actual harm
2023-09-21
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-11-27
G · Actual harm
2023-09-21
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 2023-11-06
D · Potential for more than minimal harm
2023-09-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-07
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 2023-09-08
D · Potential for more than minimal harm
2023-07-14
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-08-09
D · Potential for more than minimal harm
2023-07-07
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 2023-07-21
D · Potential for more than minimal harm
2023-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-09
D · Potential for more than minimal harm
2023-04-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-09
E · Potential for more than minimal harm
2022-07-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-07-14
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 2022-08-12
E · Potential for more than minimal harm
2022-07-14
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 2022-08-12
E · Potential for more than minimal harm
2022-07-14
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 2022-08-12
E · Potential for more than minimal harm
2022-07-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
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 2022-08-12
D · Potential for more than minimal harm
2022-07-14
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 2022-08-12
D · Potential for more than minimal harm
2022-07-14
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 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
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 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
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 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-14
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2022-08-12
F · Potential for more than minimal harm
2019-02-07
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2019-02-07
F · Potential for more than minimal harm
2019-02-07
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 2019-02-07
E · Potential for more than minimal harm
2019-02-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-04-04
E · Potential for more than minimal harm
2019-02-07
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2019-04-04
E · Potential for more than minimal harm
2019-02-07
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 2019-04-04
E · Potential for more than minimal harm
2019-02-07
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2019-02-07
D · Potential for more than minimal harm
2019-02-07
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 2019-04-04
D · Potential for more than minimal harm
2019-02-07
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 2019-04-04
D · Potential for more than minimal harm
2019-02-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-04-04
D · Potential for more than minimal harm
2019-02-07
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 2019-04-04
D · Potential for more than minimal harm
2019-02-07
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 2019-04-04
D · Potential for more than minimal harm
2019-02-07
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2019-04-04
Penalties and ownership
What sits behind the stars
$85,943
2023-06-27
Fine
Fine · fine $85,943
Fine
$0
2023-06-27
Payment Denial
Payment Denial · denial start 2023-09-27 · 61 days
61 day denial
Ownership
Bayshire LLC
5% Or Greater Direct Ownership Interest · Organization
Kirby, Scott
5% Or Greater Indirect Ownership Interest · Individual
Brar, Karanbir
Operational/Managerial Control · Individual
Kirby, Scott
Operational/Managerial Control · Individual
Tanner, David
Operational/Managerial Control · Individual
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