Cycle 1
Health 2024-10-18 · Fire 2024-10-18
28 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Sunnyvale, CA
Sunnyvale Post-Acute Center
2-star overall rating with 1-star inspections with 28 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1291 S Bernardo Avenue, Sunnyvale, CA
(408) 245-8070
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
93
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
2002-05-06
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
0.51
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.23
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.70
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,859
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.29
Baseline 24.02% · Performance 21.37% · Measure score 3.29 · Achievement 0 · Improvement 3.29
Healthcare-associated infections
3.21
Baseline 10.39% · Performance 8.39% · Measure score 3.21 · Achievement 0 · Improvement 3.21
Total nurse turnover
4.78
Performance 44.14% · Measure score 4.78 · Achievement 4.78 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.32
Baseline 3.95 hours · Performance 3.45 hours · Measure score 1.32 · Achievement 1.32 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.17% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 168 · Observed rate 7.14% · Lower 95% interval 6.82% |
| Discharge to community | 51.05% |
50.57%
0.5 pts better
|
No Different than the National Rate · Eligible stays 192 · Observed rate 41.15% · Lower 95% interval 44.02% |
| Medicare spending per beneficiary | 1.53 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 146 · Denominator 146 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 146 |
| Discharge self-care score | 62.71% |
53.69%
9 pts better
|
Numerator 37 · Denominator 59 |
| Discharge mobility score | 54.24% |
50.94%
3.3 pts better
|
Numerator 32 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 0.68% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 146 · Adjusted rate 0.57% |
| Healthcare-associated infections requiring hospitalization | 8.39% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 133 · Observed rate 11.28% · Lower 95% interval 6.12% |
| Staff COVID-19 vaccination coverage | 30.94% |
8.2%
22.7 pts better
|
Numerator 43 · Denominator 139 |
| Staff flu vaccination coverage | 61.68% |
42%
19.7 pts better
|
Numerator 103 · Denominator 167 |
| Discharge function score | 55.93% |
56.45%
0.5 pts worse
|
Numerator 33 · Denominator 59 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 54 · Denominator 54 |
| Transfer of health information to patient | 91.43% |
96.28%
4.8 pts worse
|
Numerator 64 · Denominator 70 |
| Resident COVID-19 vaccinations up to date | 32.1% |
25.2%
6.9 pts better
|
Numerator 26 · Denominator 81 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.3
0.2 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 3.4 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.5 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 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 | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.1% |
6.8%
3.3 pts worse
|
11.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 11.9% · Q3 13.6% · Q4 13.1% · 4Q avg 10.1% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
4.1%
2 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 7.0% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.5% |
13.7%
6.2 pts better
|
19.6%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 9.4% · Q3 8.2% · Q4 6.1% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
14.2%
2.7 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 12.5% · Q3 8.9% · Q4 14.3% · 4Q avg 11.5% · 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 | 2.0% |
11.0%
9 pts better
|
16.3%
14.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 7.7% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.5% |
10.7%
6.2 pts better
|
14.9%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 7.5% · Q4 6.9% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.0%
About the same
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 1.1% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.2%
About the same
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.4% |
10.9%
0.5 pts worse
|
19.8%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 3.4% · Q3 12.1% · Q4 17.0% · 4Q avg 11.4% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.7%
1.1 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.7% · Q3 3.3% · Q4 3.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
94.0%
5.8 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.6% · Q3 99.6% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
11.2%
2.3 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 9.8% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.7% · Q4 1.7% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
93.2%
4.7 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
23.2%
0.5 pts better
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 28.5% · Expected 29.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-10 · Fire 2023-04-10
23 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2020-03-12 · Fire 2020-03-12
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-18
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-18
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-18
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-15
E · Potential for more than minimal harm
2023-04-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-04-10
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-11
D · Potential for more than minimal harm
2023-04-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-05-11
D · Potential for more than minimal harm
2023-04-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-11
D · Potential for more than minimal harm
2023-04-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-11
D · Potential for more than minimal harm
2023-04-10
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-05-11
D · Potential for more than minimal harm
2023-04-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-11
D · Potential for more than minimal harm
2023-04-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-11
E · Potential for more than minimal harm
2020-03-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2020-09-03
E · Potential for more than minimal harm
2020-03-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-09-03
E · Potential for more than minimal harm
2020-03-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-09-03
D · Potential for more than minimal harm
2020-03-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-09-03
D · Potential for more than minimal harm
2020-03-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-09-03
D · Potential for more than minimal harm
2020-03-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-09-03
D · Potential for more than minimal harm
2020-03-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-09-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-11
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 2025-09-25
D · Potential for more than minimal harm
2025-09-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-09-11
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-07-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-04
D · Potential for more than minimal harm
2025-07-11
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 2025-08-04
F · Potential for more than minimal harm
2024-10-18
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 2024-11-10
F · Potential for more than minimal harm
2024-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-10
F · Potential for more than minimal harm
2024-10-18
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-11-10
E · Potential for more than minimal harm
2024-10-18
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 2024-11-10
E · Potential for more than minimal harm
2024-10-18
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-11-10
E · Potential for more than minimal harm
2024-10-18
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 2024-11-10
E · Potential for more than minimal harm
2024-10-18
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 2024-11-10
E · Potential for more than minimal harm
2024-10-18
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-18
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-18
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-18
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 2024-11-10
D · Potential for more than minimal harm
2024-10-18
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 2024-11-10
D · Potential for more than minimal harm
2024-10-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-18
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 2024-11-10
D · Potential for more than minimal harm
2024-10-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-18
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-18
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 2024-11-10
D · Potential for more than minimal harm
2024-10-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-18
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 2024-11-10
D · Potential for more than minimal harm
2024-10-18
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-10-03
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-08-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-08-07
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 2024-08-25
E · Potential for more than minimal harm
2024-03-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-02-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-19
D · Potential for more than minimal harm
2023-10-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-09-22
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-04-10
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 2023-05-09
E · Potential for more than minimal harm
2023-04-10
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 2023-05-09
E · Potential for more than minimal harm
2023-04-10
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-05-09
E · Potential for more than minimal harm
2023-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-09
E · Potential for more than minimal harm
2023-04-10
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-10
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 2023-05-09
D · Potential for more than minimal harm
2023-04-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-10
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 2023-05-09
D · Potential for more than minimal harm
2023-04-10
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-10
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-10
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-10
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 2023-05-09
D · Potential for more than minimal harm
2023-04-10
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 2023-05-09
D · Potential for more than minimal harm
2023-04-10
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-03-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-20
E · Potential for more than minimal harm
2020-03-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-04-11
E · Potential for more than minimal harm
2020-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-11
D · Potential for more than minimal harm
2020-03-12
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 2020-04-11
D · Potential for more than minimal harm
2020-03-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-04-11
D · Potential for more than minimal harm
2020-03-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-04-11
D · Potential for more than minimal harm
2020-03-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-04-11
D · Potential for more than minimal harm
2020-03-12
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 2020-04-11
D · Potential for more than minimal harm
2020-03-12
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 2020-04-11
D · Potential for more than minimal harm
2020-03-12
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 2020-04-11
D · Potential for more than minimal harm
2020-03-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2020-04-11
D · Potential for more than minimal harm
2020-03-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2020-04-11
D · Potential for more than minimal harm
2020-03-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2020-04-11
D · Potential for more than minimal harm
2020-03-12
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2020-04-11
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jamali, Mehran
Contracted Managing Employee · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Pierce, Robert
Operational/Managerial Control · Individual
Pierce, Robert
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Idylwood Care Center
Sunnyvale, CA
5-star overall rating with 4-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Mountain View Healthcare Center
Mountain View, CA
3-star overall rating with 2-star inspections with $54,912 in total fines with 24 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Los Altos Post-Acute
Los Altos, CA
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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