Cycle 1
Health 2025-12-05 · Fire 2025-12-05
24 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Los Angeles, CA
St. John Of God Retirement
2-star overall rating with 2-star inspections with $124,440 in total fines with 24 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2468 South St Andrews Place, Los Angeles, CA
(323) 731-0641
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
156
Certified beds
Average residents
142
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.27
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.37
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.85
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.49
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.05
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.19
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
0.28
CMS adjusted RN staffing hours
Adjusted total hours
4.65
CMS adjusted total nurse staffing hours
Case-mix index
1.32
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
8,060
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.94
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
3.81
Baseline 18.75% · Performance 19.66% · Measure score 3.81 · Achievement 3.81 · Improvement 0
Healthcare-associated infections
0
Baseline 9.75% · Performance 10.22% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.72
Baseline 36.05% · Performance 44.37% · Measure score 4.72 · Achievement 4.72 · Improvement 0
Adjusted total nurse staffing
2.64
Baseline 4.32 hours · Performance 3.83 hours · Measure score 2.64 · Achievement 2.64 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.93% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 136 · Observed rate 7.35% · Lower 95% interval 7.15% |
| Discharge to community | 32.75% |
50.57%
17.8 pts worse
|
Worse than the National Rate · Eligible stays 106 · Observed rate 25.47% · Lower 95% interval 25.07% |
| Medicare spending per beneficiary | 1.66 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 85.05% |
95.27%
10.2 pts worse
|
Numerator 91 · Denominator 107 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 107 |
| Discharge self-care score | 44.3% |
53.69%
9.4 pts worse
|
Numerator 35 · Denominator 79 |
| Discharge mobility score | 40.51% |
50.94%
10.4 pts worse
|
Numerator 32 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 0.93% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 107 · Adjusted rate 0.62% |
| Healthcare-associated infections requiring hospitalization | 10.22% |
7.12%
3.1 pts worse
|
Worse than the National Rate · Eligible stays 116 · Observed rate 13.79% · Lower 95% interval 7.45% |
| Staff COVID-19 vaccination coverage | 4.76% |
8.2%
3.4 pts worse
|
Numerator 5 · Denominator 105 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 40.51% |
56.45%
15.9 pts worse
|
Numerator 32 · Denominator 79 |
| Transfer of health information to provider | 92.31% |
95.95%
3.6 pts worse
|
Numerator 24 · Denominator 26 |
| Transfer of health information to patient | 90% |
96.28%
6.3 pts worse
|
Numerator 18 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 6.25% |
25.2%
18.9 pts worse
|
Numerator 3 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.3
0.5 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.6
1 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.4 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
98.5%
9 pts worse
|
93.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.1% · Q2 90.8% · Q3 90.0% · Q4 89.1% · 4Q avg 89.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.6% |
98.2%
13.6 pts worse
|
95.5%
10.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
1.6%
0.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.7% · Q3 0.7% · Q4 0.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
4.1%
2.9 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 11.5% · Q3 6.9% · Q4 4.4% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.5% |
13.7%
5.2 pts better
|
19.6%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 9.7% · Q3 9.6% · Q4 7.3% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
14.2%
4.5 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 10.2% · Q3 11.2% · Q4 7.1% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.7% |
0.4%
0.3 pts worse
|
0.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 2.1% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.5% |
11.0%
7.5 pts worse
|
16.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 8.5% · Q3 28.2% · Q4 16.7% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.9% |
10.7%
13.2 pts worse
|
14.9%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 17.3% · Q3 32.7% · Q4 21.1% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.0%
0.7 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.1% · Q3 1.9% · Q4 1.5% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.3% |
1.2%
5.1 pts worse
|
1.7%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.5% · Q3 6.1% · Q4 7.0% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.2% |
10.9%
0.3 pts worse
|
19.8%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 13.7% · Q3 8.6% · Q4 11.7% · 4Q avg 11.2% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.7%
1.5 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 4.8% · Q3 2.8% · Q4 4.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 39.4% |
94.0%
54.6 pts worse
|
81.7%
42.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.3% · Q2 44.7% · Q3 25.0% · Q4 29.7% · 4Q avg 39.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.2% |
11.2%
6 pts better
|
12.0%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.2% · Observed 4.5% · Expected 9.7% · 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 · 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 | 43.6% |
93.2%
49.6 pts worse
|
79.7%
36.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 43.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.4% |
23.2%
8.8 pts better
|
23.9%
9.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.4% · Observed 12.4% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-04 · Fire 2024-10-04
31 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-10-02 · Fire 2023-10-02
22 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-12-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-12-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-12-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-12-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-12-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-12-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-12-24
F · Potential for more than minimal harm
2024-10-04
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-10-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-10-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-10-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-10-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-10-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-10-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-10-04
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 2024-10-24
E · Potential for more than minimal harm
2024-10-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-10-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-04
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 2024-10-24
D · Potential for more than minimal harm
2024-10-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-24
F · Potential for more than minimal harm
2023-10-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-02
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-02
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Not marked corrected
D · Potential for more than minimal harm
2026-01-15
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-15
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.
Not marked corrected
F · Potential for more than minimal harm
2025-12-05
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 2025-12-26
E · Potential for more than minimal harm
2025-12-05
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-12-05
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 2025-12-26
E · Potential for more than minimal harm
2025-12-05
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 2025-12-26
E · Potential for more than minimal harm
2025-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
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 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
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 2025-12-26
D · Potential for more than minimal harm
2025-12-05
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 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
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 2025-12-26
D · Potential for more than minimal harm
2025-12-05
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 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
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 2025-12-26
D · Potential for more than minimal harm
2025-12-05
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 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-12-26
B · Minimal harm
2025-12-05
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 2025-12-26
B · Minimal harm
2025-12-05
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-03-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-21
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 2025-03-12
F · Potential for more than minimal harm
2024-10-04
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 2024-10-25
F · Potential for more than minimal harm
2024-10-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-10-04
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-10-04
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 2024-10-25
E · Potential for more than minimal harm
2024-10-04
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 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
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 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
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 2024-10-25
D · Potential for more than minimal harm
2024-10-04
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 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
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 2024-10-25
D · Potential for more than minimal harm
2024-10-04
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-04
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 2024-10-25
B · Minimal harm
2024-08-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-22
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 2024-08-05
D · Potential for more than minimal harm
2024-07-03
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-12
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-12
G · Actual harm
2024-05-22
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 2024-06-21
E · Potential for more than minimal harm
2024-05-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-04-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-15
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 2024-04-24
D · Potential for more than minimal harm
2024-02-16
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 2024-02-28
G · Actual harm
2024-01-05
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 2024-01-30
D · Potential for more than minimal harm
2024-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-12-21
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 2024-01-08
G · Actual harm
2023-11-20
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 2024-01-26
D · Potential for more than minimal harm
2023-11-20
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 2024-01-26
J · Immediate jeopardy
2023-10-02
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 2023-10-26
E · Potential for more than minimal harm
2023-10-02
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 2023-10-26
E · Potential for more than minimal harm
2023-10-02
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 2023-10-26
E · Potential for more than minimal harm
2023-10-02
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 2023-10-26
E · Potential for more than minimal harm
2023-10-02
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-10-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-10-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-10-02
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-10-02
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 2023-10-26
D · Potential for more than minimal harm
2023-10-02
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 2023-10-26
D · Potential for more than minimal harm
2023-10-02
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-10-02
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-10-02
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-08-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-03-20
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 2023-04-05
Penalties and ownership
What sits behind the stars
$14,050
2024-05-22
Fine
Fine · fine $14,050
Fine
$0
2024-05-22
Payment Denial
Payment Denial · denial start 2024-06-21 · 45 days
45 day denial
$95,479
2023-11-20
Fine
Fine · fine $95,479
Fine
$14,911
2023-10-02
Fine
Fine · fine $14,911
Fine
Ownership
St. John Of God Retirement And Care Center
5% Or Greater Direct Ownership Interest · Organization
Bassemier, Bro Michael
Corporate Director · Individual
C & S Healthcare Services
Operational/Managerial Control · Organization
Castillo, Carlos
Operational/Managerial Control · Individual
Castillo, Carlos
Contracted Managing Employee · Individual
De La Rosa, Jose
Corporate Director · Individual
De La Rosa, Jose
Corporate Officer · Individual
Ignatius, Brother
Corporate Director · Individual
St. John Of God Retirement And Care Center
Operational/Managerial Control · Organization
Uomoto, Kirk
Operational/Managerial Control · Individual
Uomoto, Kirk
Corporate Director · Individual
Uomoto, Kirk
Contracted Managing Employee · Individual
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#3
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