Cycle 1
Health 2025-02-28 · Fire 2025-02-28
42 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Lancaster, CA
The Ellison John Transitional Care Center
1-star overall rating with 1-star inspections with $189,236 in total fines with 42 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
43830 10th Street West, Lancaster, CA
(661) 494-8600
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
170
Certified beds
Average residents
154
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Abby Gl, LLC
Operator or chain grouping
Approved since
2017-09-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 2 overall / 2 health / 4 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
0.52
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.74
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.91
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.26
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.54
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.74
CMS adjusted total nurse staffing hours
Case-mix index
1.79
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,689
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9890
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.15
Baseline 22.21% · Performance 20.84% · Measure score 2.15 · Achievement 1.28 · Improvement 2.15
Healthcare-associated infections
5.31
Baseline 14.34% · Performance 8.91% · Measure score 5.31 · Achievement 0 · Improvement 5.31
Total nurse turnover
4.81
Baseline 44.15% · Performance 44.04% · Measure score 4.81 · Achievement 4.81 · Improvement 0
Adjusted total nurse staffing
1.86
Baseline 4.27 hours · Performance 3.61 hours · Measure score 1.86 · Achievement 1.86 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.8% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 295 · Observed rate 13.22% · Lower 95% interval 8.67% |
| Discharge to community | 53.82% |
50.57%
3.2 pts better
|
No Different than the National Rate · Eligible stays 338 · Observed rate 45.27% · Lower 95% interval 48.5% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 94.39% |
95.27%
0.9 pts worse
|
Numerator 202 · Denominator 214 |
| Falls with major injury | 0.47% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 214 |
| Discharge self-care score | 43.7% |
53.69%
10 pts worse
|
Numerator 59 · Denominator 135 |
| Discharge mobility score | 23.7% |
50.94%
27.2 pts worse
|
Numerator 32 · Denominator 135 |
| Pressure ulcers or injuries, new or worsened | 0.47% |
2.29%
1.8 pts better
|
Numerator 1 · Denominator 213 · Adjusted rate 0.32% |
| Healthcare-associated infections requiring hospitalization | 8.91% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 183 · Observed rate 11.48% · Lower 95% interval 6% |
| Staff COVID-19 vaccination coverage | 20.62% |
8.2%
12.4 pts better
|
Numerator 60 · Denominator 291 |
| Staff flu vaccination coverage | 42.9% |
42%
0.9 pts better
|
Numerator 160 · Denominator 373 |
| Discharge function score | 40% |
56.45%
16.5 pts worse
|
Numerator 54 · Denominator 135 |
| Transfer of health information to provider | 98.7% |
95.95%
2.8 pts better
|
Numerator 152 · Denominator 154 |
| Transfer of health information to patient | 96.43% |
96.28%
0.2 pts better
|
Numerator 27 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 11.46% |
25.2%
13.7 pts worse
|
Numerator 11 · Denominator 96 |
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 2.2 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.6
0.8 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.3 · 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 | 1.2% |
1.6%
0.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.0% · Q3 1.0% · Q4 2.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.4% |
6.8%
3.6 pts worse
|
11.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 12.5% · Q3 9.4% · Q4 10.3% · 4Q avg 10.4% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
4.1%
3.3 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.1% · Q4 1.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.0% |
13.7%
1.7 pts better
|
19.6%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 12.6% · Q3 10.4% · Q4 10.3% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.7% |
14.2%
9.5 pts better
|
16.7%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 4.4% · Q3 4.3% · Q4 4.4% · 4Q avg 4.7% · 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 | 6.0% |
11.0%
5 pts better
|
16.3%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.1% |
10.7%
8.6 pts better
|
14.9%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 1.7% · Q4 1.6% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.0% |
10.9%
5.9 pts better
|
19.8%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 4.0% · Q3 1.4% · Q4 5.3% · 4Q avg 5.0% |
| Percentage of long-stay residents with pressure ulcers | 10.9% |
4.7%
6.2 pts worse
|
5.1%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 11.4% · Q3 10.7% · Q4 10.0% · 4Q avg 10.9% · 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 | 18.9% |
11.2%
7.7 pts worse
|
12.0%
6.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 19.3% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.4% · Q3 2.0% · Q4 1.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.7% |
93.2%
5.5 pts better
|
79.7%
19 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.8% |
23.2%
1.4 pts better
|
23.9%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 24.4% · Expected 26.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-23 · Fire 2024-02-23
30 health deficiencies
Top issue: Resident Assessment and Care Planning (9 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-02-03 · Fire 2023-02-03
36 health deficiencies
Top issue: Pharmacy Service (8 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-24
E · Potential for more than minimal harm
2024-02-23
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-23
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-11
C · Minimal harm
2024-02-23
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-03-11
D · Potential for more than minimal harm
2023-02-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-30
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 2025-12-31
E · Potential for more than minimal harm
2025-12-26
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 2025-12-29
E · Potential for more than minimal harm
2025-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-11
E · Potential for more than minimal harm
2025-12-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-12-01
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 2025-12-11
D · Potential for more than minimal harm
2025-12-01
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-12-01
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 2025-12-11
G · Actual harm
2025-11-12
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 2025-12-04
D · Potential for more than minimal harm
2025-11-12
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 2025-12-04
D · Potential for more than minimal harm
2025-11-12
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 2025-12-04
D · Potential for more than minimal harm
2025-09-11
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 2025-09-25
D · Potential for more than minimal harm
2025-09-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-07-22
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 2025-08-01
D · Potential for more than minimal harm
2025-05-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-05-05
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-22
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 2025-05-09
D · Potential for more than minimal harm
2025-04-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-02-28
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 2025-03-25
E · Potential for more than minimal harm
2025-02-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-28
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 2025-03-25
E · Potential for more than minimal harm
2025-02-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-28
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 2025-03-25
E · Potential for more than minimal harm
2025-02-28
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-28
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 2025-03-25
E · Potential for more than minimal harm
2025-02-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-28
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 2025-03-25
D · Potential for more than minimal harm
2025-02-28
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-28
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 2025-03-25
D · Potential for more than minimal harm
2025-02-28
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-28
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 2025-03-25
D · Potential for more than minimal harm
2025-02-28
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 2025-03-25
D · Potential for more than minimal harm
2025-02-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-28
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-28
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-25
B · Minimal harm
2025-02-28
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-03-25
B · Minimal harm
2025-02-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-01-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-12-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-23
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-23
J · Immediate jeopardy
2024-11-22
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 2024-11-25
D · Potential for more than minimal harm
2024-11-22
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 2024-11-25
D · Potential for more than minimal harm
2024-11-22
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 2024-11-25
E · Potential for more than minimal harm
2024-11-20
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-07-26
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 2024-08-20
E · Potential for more than minimal harm
2024-02-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-23
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 2024-03-22
E · Potential for more than minimal harm
2024-02-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-23
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 2024-03-22
E · Potential for more than minimal harm
2024-02-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-23
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-23
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-23
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 2024-03-22
D · Potential for more than minimal harm
2024-02-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-22
B · Minimal harm
2024-02-23
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-03-22
B · Minimal harm
2024-02-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-01-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-21
D · Potential for more than minimal harm
2024-01-21
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 2024-01-21
D · Potential for more than minimal harm
2024-01-21
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 2024-01-21
D · Potential for more than minimal harm
2024-01-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-21
D · Potential for more than minimal harm
2023-12-28
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2024-01-13
J · Immediate jeopardy
2023-12-17
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 2024-01-12
J · Immediate jeopardy
2023-12-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-17
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 2024-01-12
D · Potential for more than minimal harm
2023-12-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-09-19
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-27
E · Potential for more than minimal harm
2023-08-15
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.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-15
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 2023-09-08
D · Potential for more than minimal harm
2023-08-15
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-15
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 2023-09-08
D · Potential for more than minimal harm
2023-08-15
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 2023-09-08
D · Potential for more than minimal harm
2023-08-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-04-30
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2023-05-29
G · Actual harm
2023-02-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-05
E · Potential for more than minimal harm
2023-02-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-05
E · Potential for more than minimal harm
2023-02-03
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 2023-03-05
E · Potential for more than minimal harm
2023-02-03
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-03-05
E · Potential for more than minimal harm
2023-02-03
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 2023-03-05
D · Potential for more than minimal harm
2023-02-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-03
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-02-03
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-02-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-02-03
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 2023-03-05
D · Potential for more than minimal harm
2023-02-03
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 2023-03-05
D · Potential for more than minimal harm
2023-02-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-02-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-03-05
D · Potential for more than minimal harm
2023-02-03
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 2023-03-05
D · Potential for more than minimal harm
2023-02-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-05
Penalties and ownership
What sits behind the stars
$125,220
2024-11-20
Fine
Fine · fine $125,220
Fine
$0
2024-11-20
Payment Denial
Payment Denial · denial start 2024-12-24 · 17 days
17 day denial
$64,016
2023-12-17
Fine
Fine · fine $64,016
Fine
$0
2023-12-17
Payment Denial
Payment Denial · denial start 2024-01-17 · 4 days
4 day denial
Ownership
Abby Gl LLC
Limited Partnership Interest · Organization
Carlson, Shane
Operational/Managerial Control · Individual
Lynch, Jose
Operational/Managerial Control · Individual
Premiere Wellness Of Lancaster Gp LLC
General Partnership Interest · Organization
Pursue Health LLC
Operational/Managerial Control · Organization
Rechnitz, Shlomo
Limited Partnership Interest · Individual
Siddiqui, Shahid
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Desert Canyon Post Acute, LLC
Lancaster, CA
1-star overall rating with 1-star inspections with 30 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Mirage Post Acute
Lancaster, CA
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $117,614 in total fines with 86 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Antelope Valley Care Center
Lancaster, CA
1-star overall rating with 1-star inspections with Special Focus status with $124,690 in total fines with 55 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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