Cycle 1
Health 2024-11-18 · Fire 2024-11-18
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Sunnyvale, CA
Sunnyvale Gardens Post Acute
3-star overall rating with 2-star inspections with $43,176 in total fines with 18 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
1150 Tilton Drive, Sunnyvale, CA
(408) 735-7200
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
134
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1991-01-03
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
0.58
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.63
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.57
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,042
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.80% · Performance 21.26% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.28
Baseline 5.73% · Performance 6.85% · Measure score 3.28 · Achievement 3.28 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.18
Baseline 4.12 hours · Performance 3.70 hours · Measure score 2.18 · Achievement 2.18 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.94% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 318 · Observed rate 11.64% · Lower 95% interval 9.51% |
| Discharge to community | 62.05% |
50.57%
11.5 pts better
|
Better than the National Rate · Eligible stays 339 · Observed rate 57.82% · Lower 95% interval 57.3% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 248 · Denominator 248 |
| Falls with major injury | 0.4% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 248 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 110 · Denominator 165 |
| Discharge mobility score | 58.79% |
50.94%
7.9 pts better
|
Numerator 97 · Denominator 165 |
| Pressure ulcers or injuries, new or worsened | 0.4% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 248 · Adjusted rate 0.34% |
| Healthcare-associated infections requiring hospitalization | 6.85% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 213 · Observed rate 6.57% · Lower 95% interval 4.37% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 154 |
| Staff flu vaccination coverage | 97.49% |
42%
55.5 pts better
|
Numerator 311 · Denominator 319 |
| Discharge function score | 86.67% |
56.45%
30.2 pts better
|
Numerator 143 · Denominator 165 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 170 · Denominator 170 |
| Transfer of health information to patient | 88.57% |
96.28%
7.7 pts worse
|
Numerator 31 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 11.97% |
25.2%
13.2 pts worse
|
Numerator 17 · Denominator 142 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.3
0.2 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 3.1 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · 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 | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
1.6%
1.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
6.8%
3.4 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 3.3% · Q3 0.0% · Q4 2.3% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
4.1%
3.5 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.8% |
13.7%
5.9 pts better
|
19.6%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 7.9% · Q3 9.6% · Q4 4.7% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.8% |
14.2%
8.4 pts better
|
16.7%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 12.5% · Q3 1.9% · Q4 1.7% · 4Q avg 5.8% · 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 | 3.2% |
11.0%
7.8 pts better
|
16.3%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.3% · Q3 0.0% · Q4 3.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
10.7%
6.4 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.8% · Q3 0.0% · Q4 7.5% · 4Q avg 4.3% · 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 | 11.7% |
10.9%
0.8 pts worse
|
19.8%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 12.8% · Q3 3.0% · Q4 7.2% · 4Q avg 11.7% |
| Percentage of long-stay residents with pressure ulcers | 1.4% |
4.7%
3.3 pts better
|
5.1%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.2% · Q3 0.0% · Q4 1.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
11.2%
2.9 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.3% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.4% |
23.2%
2.8 pts better
|
23.9%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.4% · Observed 21.3% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-18 · Fire 2022-11-18
24 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2020-02-28 · Fire 2020-02-28
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-18
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-11-18
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-11-18
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-11-18
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-11-18
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-11-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-11-18
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-11-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-11-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-18
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-18
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-12-06
E · Potential for more than minimal harm
2022-11-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-08
E · Potential for more than minimal harm
2022-11-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-18
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-18
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-08
E · Potential for more than minimal harm
2020-02-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-08-28
D · Potential for more than minimal harm
2020-02-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-08-28
D · Potential for more than minimal harm
2020-02-28
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 2020-08-28
D · Potential for more than minimal harm
2020-02-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-08-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-04
K · Immediate jeopardy
2024-11-27
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 2024-12-16
F · Potential for more than minimal harm
2024-11-18
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 2024-12-14
E · Potential for more than minimal harm
2024-11-18
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 2024-12-14
E · Potential for more than minimal harm
2024-11-18
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 2024-12-14
E · Potential for more than minimal harm
2024-11-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-11-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-11-18
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 2024-12-14
E · Potential for more than minimal harm
2024-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-18
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 2024-12-14
D · Potential for more than minimal harm
2024-11-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-18
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 2024-12-14
D · Potential for more than minimal harm
2024-11-18
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-18
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 2024-12-14
D · Potential for more than minimal harm
2024-11-18
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-18
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-11-18
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-12-14
G · Actual harm
2024-08-15
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.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-08-15
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-08-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-25
E · Potential for more than minimal harm
2024-06-13
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 2024-07-05
D · Potential for more than minimal harm
2023-03-13
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 2023-03-31
D · Potential for more than minimal harm
2023-03-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-07
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 2023-03-24
F · Potential for more than minimal harm
2022-11-18
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 2022-12-16
E · Potential for more than minimal harm
2022-11-18
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 2022-12-16
E · Potential for more than minimal harm
2022-11-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-18
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 2022-12-16
E · Potential for more than minimal harm
2022-11-18
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 2022-12-16
E · Potential for more than minimal harm
2022-11-18
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 2022-12-16
E · Potential for more than minimal harm
2022-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-18
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 2022-12-16
D · Potential for more than minimal harm
2022-11-18
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-18
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 2022-12-16
D · Potential for more than minimal harm
2022-11-18
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 2022-12-16
D · Potential for more than minimal harm
2022-11-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-18
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 2022-12-16
D · Potential for more than minimal harm
2022-11-18
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 2022-12-16
D · Potential for more than minimal harm
2022-11-18
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-18
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 2022-12-16
D · Potential for more than minimal harm
2022-11-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-16
F · Potential for more than minimal harm
2020-02-28
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 2020-03-28
E · Potential for more than minimal harm
2020-02-28
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 2020-03-28
E · Potential for more than minimal harm
2020-02-28
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 2020-03-28
D · Potential for more than minimal harm
2020-02-28
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 2020-03-28
D · Potential for more than minimal harm
2020-02-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-03-28
D · Potential for more than minimal harm
2020-02-28
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 2020-03-28
D · Potential for more than minimal harm
2020-02-28
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2020-03-28
D · Potential for more than minimal harm
2020-02-28
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 2020-03-28
D · Potential for more than minimal harm
2020-02-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-03-28
D · Potential for more than minimal harm
2020-02-28
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 2020-03-28
D · Potential for more than minimal harm
2020-02-28
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 2020-03-28
Penalties and ownership
What sits behind the stars
$43,176
2024-11-18
Fine
Fine · fine $43,176
Fine
$0
2024-06-13
Payment Denial
Payment Denial · denial start 2024-08-31 · 25 days
25 day denial
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Operational/Managerial Control · Individual
Daquigan, Maria
Operational/Managerial Control · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jamali, Mehran
Operational/Managerial Control · Individual
Jergensen, Joshua
Operational/Managerial Control · Individual
Mitchell, John
Operational/Managerial Control · 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
Pierce, Robert
Operational/Managerial Control · Individual
Truist Bank
5% Or Greater Mortgage Interest · Organization
Nearby options
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4-star overall rating with 3-star inspections with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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2-star overall rating with 1-star inspections with 28 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Idylwood Care Center
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5-star overall rating with 4-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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