Cycle 1
Health 2024-10-24 · Fire 2024-10-24
25 health deficiencies
Top issue: Resident Rights (9 deficiencies)
20 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (7 deficiencies)
San Diego, CA
The Pavilion At Ocean Point
1-star overall rating with 2-star inspections with 25 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
3202 Duke Street, San Diego, CA
(619) 224-4141
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
133
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacific Healthcare Holdings
Operator or chain grouping
Approved since
1969-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 2 overall / 2 health / 3 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
0.36
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.22
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.89
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.43
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,489
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.91% · Performance 23.73% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.98% · Performance 9.41% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.23
Baseline 73.60% · Performance 70.06% · Measure score 0.23 · Achievement 0 · Improvement 0.23
Adjusted total nurse staffing
1.62
Baseline 3.42 hours · Performance 3.54 hours · Measure score 1.62 · Achievement 1.62 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.84% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 116 · Observed rate 14.66% · Lower 95% interval 9.37% |
| Discharge to community | 41.57% |
50.57%
9 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 30.86% · Lower 95% interval 30.88% |
| Medicare spending per beneficiary | 1.44 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 98.89% |
95.27%
3.6 pts better
|
Numerator 89 · Denominator 90 |
| Falls with major injury | 1.11% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 90 |
| Discharge self-care score | 47.83% |
53.69%
5.9 pts worse
|
Numerator 22 · Denominator 46 |
| Discharge mobility score | 36.96% |
50.94%
14 pts worse
|
Numerator 17 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 3 · Denominator 90 · Adjusted rate 2.51% |
| Healthcare-associated infections requiring hospitalization | 9.41% |
7.12%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 14.47% · Lower 95% interval 5.91% |
| Staff COVID-19 vaccination coverage | 22.7% |
8.2%
14.5 pts better
|
Numerator 37 · Denominator 163 |
| Staff flu vaccination coverage | 70.67% |
42%
28.7 pts better
|
Numerator 159 · Denominator 225 |
| Discharge function score | 39.13% |
56.45%
17.3 pts worse
|
Numerator 18 · Denominator 46 |
| Transfer of health information to provider | 81.58% |
95.95%
14.4 pts worse
|
Numerator 31 · Denominator 38 |
| Transfer of health information to patient | 78.26% |
96.28%
18 pts worse
|
Numerator 18 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 11.43% |
25.2%
13.8 pts worse
|
Numerator 4 · Denominator 35 |
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 3.4 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
1.6
1.6 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.7 · 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 | 97.5% |
98.2%
0.7 pts worse
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
1.6%
0.3 pts worse
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 1.0% · Q4 3.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.9% |
6.8%
1.1 pts worse
|
11.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 6.9% · Q3 4.1% · Q4 7.6% · 4Q avg 7.9% |
| 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 1.0% · Q2 1.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
13.7%
0.2 pts worse
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 14.3% · Q3 13.7% · Q4 12.8% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
14.2%
2.1 pts better
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 13.9% · Q3 10.0% · Q4 10.7% · 4Q avg 12.1% · 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 | 2.1% |
11.0%
8.9 pts better
|
16.3%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.7% · Q3 3.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.9% |
10.7%
2.8 pts better
|
14.9%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 9.9% · Q3 6.7% · Q4 9.1% · 4Q avg 7.9% · 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 | 0.2% |
1.2%
1 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.6% |
10.9%
5.3 pts better
|
19.8%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.1% · Q3 1.0% · Q4 17.7% · 4Q avg 5.6% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.7%
1 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.2% · Q3 2.3% · Q4 0.8% · 4Q avg 3.7% · 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 | 16.0% |
11.2%
4.8 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 17.6% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.3% · Q4 1.5% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.2% |
93.2%
3 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
23.2%
2.6 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 28.4% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
18 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-10-19 · Fire 2022-10-19
43 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-11
F · Potential for more than minimal harm
2024-10-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-24
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-24
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-24
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 2024-11-26
F · Potential for more than minimal harm
2024-10-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-26
F · Potential for more than minimal harm
2024-10-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-10-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-10-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-10-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-24
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-24
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-11-26
D · Potential for more than minimal harm
2023-10-26
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
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 2023-11-17
D · Potential for more than minimal harm
2023-10-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-17
F · Potential for more than minimal harm
2022-10-19
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-11-14
F · Potential for more than minimal harm
2022-10-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-14
F · Potential for more than minimal harm
2022-10-19
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-11-14
F · Potential for more than minimal harm
2022-10-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-19
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-19
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-19
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-19
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-11-14
C · Minimal harm
2022-10-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-08-13
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 2025-09-12
D · Potential for more than minimal harm
2025-07-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-31
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 2025-08-29
D · Potential for more than minimal harm
2025-06-24
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 2025-07-17
D · Potential for more than minimal harm
2025-06-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-04-15
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 2025-04-20
E · Potential for more than minimal harm
2024-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-24
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-24
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 2024-11-21
D · Potential for more than minimal harm
2024-10-24
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 2024-11-21
D · Potential for more than minimal harm
2024-10-24
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 2024-11-21
D · Potential for more than minimal harm
2024-10-24
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-24
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-24
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 2024-11-21
D · Potential for more than minimal harm
2024-10-24
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 2024-11-21
D · Potential for more than minimal harm
2024-10-24
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 2024-11-21
D · Potential for more than minimal harm
2024-10-24
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 2024-11-21
D · Potential for more than minimal harm
2024-10-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-24
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 2024-11-21
D · Potential for more than minimal harm
2024-10-24
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 2024-11-21
D · Potential for more than minimal harm
2024-10-24
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 2024-11-21
D · Potential for more than minimal harm
2024-10-24
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-24
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-29
E · Potential for more than minimal harm
2024-09-24
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 2024-10-03
E · Potential for more than minimal harm
2024-09-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-03
E · Potential for more than minimal harm
2024-09-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-09-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-09-24
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 2024-10-03
D · Potential for more than minimal harm
2024-09-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-09-04
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-06-17
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 2024-07-15
D · Potential for more than minimal harm
2024-05-21
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-04-18
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 2024-05-15
D · Potential for more than minimal harm
2024-01-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-23
D · Potential for more than minimal harm
2023-12-21
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
D · Potential for more than minimal harm
2023-12-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-10-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-26
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 2023-12-05
D · Potential for more than minimal harm
2023-10-26
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-26
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 2023-12-05
D · Potential for more than minimal harm
2023-10-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-22
E · Potential for more than minimal harm
2023-09-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-11
E · Potential for more than minimal harm
2023-09-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-09-24
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 2023-10-11
D · Potential for more than minimal harm
2023-09-18
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 2023-10-09
D · Potential for more than minimal harm
2023-09-14
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-09-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-09-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-04
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-08-03
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 2023-08-31
D · Potential for more than minimal harm
2023-08-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-06-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-04-21
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 2023-05-16
D · Potential for more than minimal harm
2023-04-12
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 2023-04-30
D · Potential for more than minimal harm
2023-03-22
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 2023-03-28
E · Potential for more than minimal harm
2022-10-19
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-11-19
E · Potential for more than minimal harm
2022-10-19
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2022-11-19
E · Potential for more than minimal harm
2022-10-19
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-11-19
D · Potential for more than minimal harm
2022-10-19
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-11-19
D · Potential for more than minimal harm
2022-10-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-11-19
D · Potential for more than minimal harm
2022-10-19
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 2022-11-19
D · Potential for more than minimal harm
2022-10-19
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2022-11-19
D · Potential for more than minimal harm
2022-10-19
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-11-19
D · Potential for more than minimal harm
2022-10-19
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 2022-11-19
D · Potential for more than minimal harm
2022-10-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-11-19
D · Potential for more than minimal harm
2022-10-19
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 2022-11-19
D · Potential for more than minimal harm
2022-10-19
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 2022-11-19
D · Potential for more than minimal harm
2022-10-19
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2022-11-19
D · Potential for more than minimal harm
2022-10-19
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 2022-11-19
D · Potential for more than minimal harm
2022-10-19
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-11-19
D · Potential for more than minimal harm
2022-10-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-11-19
D · Potential for more than minimal harm
2022-10-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-11-19
D · Potential for more than minimal harm
2022-10-19
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2022-11-19
D · Potential for more than minimal harm
2022-10-19
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 2022-11-19
D · Potential for more than minimal harm
2022-10-19
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 2022-11-19
D · Potential for more than minimal harm
2022-10-19
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 2022-11-19
D · Potential for more than minimal harm
2022-10-19
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-11-19
D · Potential for more than minimal harm
2022-10-19
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-11-19
Penalties and ownership
What sits behind the stars
Ownership
Pacific Healthcare Holdings, Inc.
5% Or Greater Direct Ownership Interest · Organization
Blonder, David
5% Or Greater Direct Ownership Interest · Individual
Katz Healthcare Investment Partnership
5% Or Greater Direct Ownership Interest · Organization
Majer, Sol
5% Or Greater Direct Ownership Interest · Individual
Rajpara, Sanjay
Operational/Managerial Control · Individual
Rechnitz, Shlomo
Operational/Managerial Control · Individual
Rockport Administrative Services, LLC
Operational/Managerial Control · Organization
Whimpey, Kyle
Operational/Managerial Control · Individual
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#3
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