Cycle 1
Health 2025-04-28 · Fire 2025-04-28
32 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fullerton, CA
The Pavilion At Sunny Hills
2-star overall rating with 2-star inspections with 32 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2222 N. Harbor Blvd., Fullerton, CA
(714) 992-5701
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
300
Certified beds
Average residents
186
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Abby Gl, LLC
Operator or chain grouping
Approved since
1999-01-19
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
0.34
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.46
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.42
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.91
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.21
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
0.32
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,649
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.52
Baseline 20.13% · Performance 19.80% · Measure score 3.52 · Achievement 3.52 · Improvement 0.57
Healthcare-associated infections
0.57
Baseline 6.33% · Performance 7.66% · Measure score 0.57 · Achievement 0.57 · Improvement 0
Total nurse turnover
5.09
Baseline 44.02% · Performance 42.86% · Measure score 5.09 · Achievement 5.09 · Improvement 0.11
Adjusted total nurse staffing
2.48
Baseline 3.75 hours · Performance 3.78 hours · Measure score 2.48 · Achievement 2.48 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.55% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 400 · Observed rate 10% · Lower 95% interval 8.12% |
| Discharge to community | 56.49% |
50.57%
5.9 pts better
|
Better than the National Rate · Eligible stays 397 · Observed rate 50.38% · Lower 95% interval 51.68% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 327 · Denominator 327 |
| Falls with major injury | 0.61% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 327 |
| Discharge self-care score | 49.36% |
53.69%
4.3 pts worse
|
Numerator 77 · Denominator 156 |
| Discharge mobility score | 55.13% |
50.94%
4.2 pts better
|
Numerator 86 · Denominator 156 |
| Pressure ulcers or injuries, new or worsened | 0.92% |
2.29%
1.4 pts better
|
Numerator 3 · Denominator 327 · Adjusted rate 0.68% |
| Healthcare-associated infections requiring hospitalization | 7.66% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 272 · Observed rate 8.46% · Lower 95% interval 4.94% |
| Staff COVID-19 vaccination coverage | 4.11% |
8.2%
4.1 pts worse
|
Numerator 13 · Denominator 316 |
| Staff flu vaccination coverage | 5.2% |
42%
36.8 pts worse
|
Numerator 22 · Denominator 423 |
| Discharge function score | 51.92% |
56.45%
4.5 pts worse
|
Numerator 81 · Denominator 156 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 236 · Denominator 236 |
| Transfer of health information to patient | 97.92% |
96.28%
1.6 pts better
|
Numerator 47 · Denominator 48 |
| Resident COVID-19 vaccinations up to date | 21.71% |
25.2%
3.5 pts worse
|
Numerator 38 · Denominator 175 |
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 2.6 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.6
0.5 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.5 · 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 | 1.4% |
1.6%
0.2 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.8% · Q3 1.7% · Q4 1.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
6.8%
6 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
4.1%
3.2 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 9.8% · Q3 4.5% · Q4 8.6% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
13.7%
0.3 pts worse
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 12.1% · Q3 13.9% · Q4 19.3% · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
14.2%
4.2 pts worse
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 19.3% · Q3 20.4% · Q4 17.6% · 4Q avg 18.4% · 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 | 10.4% |
11.0%
0.6 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 14.6% · Q3 2.0% · Q4 14.2% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
10.7%
5.6 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.0% · Q3 4.1% · Q4 6.6% · 4Q avg 5.1% · 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 | 0.2% |
1.2%
1 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · 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 | 7.6% |
10.9%
3.3 pts better
|
19.8%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 11.5% · Q3 7.5% · Q4 5.6% · 4Q avg 7.6% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.7%
3 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.3% · Q3 2.2% · Q4 1.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
94.0%
4.8 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 99.0% · Q3 99.2% · Q4 98.6% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.7% |
11.2%
3.5 pts worse
|
12.0%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 15.8% · Expected 12.0% · 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 1.3% · Q2 1.0% · Q3 1.2% · Q4 1.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
93.2%
5.9 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.1% |
23.2%
2.9 pts worse
|
23.9%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.1% · Observed 29.0% · Expected 26.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-07 · Fire 2023-12-07
26 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-11-16 · Fire 2021-11-16
23 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
8 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-28
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-07
E · Potential for more than minimal harm
2023-12-07
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-01-08
E · Potential for more than minimal harm
2023-12-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-01-08
E · Potential for more than minimal harm
2023-12-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-08
D · Potential for more than minimal harm
2021-11-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-16
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 2021-12-17
D · Potential for more than minimal harm
2021-11-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-16
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-12-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-12-08
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 2025-12-25
D · Potential for more than minimal harm
2025-12-08
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 2025-12-25
D · Potential for more than minimal harm
2025-07-10
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 2025-07-23
B · Minimal harm
2025-05-28
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 2025-06-16
E · Potential for more than minimal harm
2025-04-28
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 2025-05-28
D · Potential for more than minimal harm
2025-04-28
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 2025-05-28
D · Potential for more than minimal harm
2025-04-28
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-28
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 2025-05-28
D · Potential for more than minimal harm
2025-04-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-28
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 2025-05-28
D · Potential for more than minimal harm
2025-04-28
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 2025-05-28
D · Potential for more than minimal harm
2025-04-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-28
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-28
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 2025-05-28
D · Potential for more than minimal harm
2025-04-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-28
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 2025-05-28
D · Potential for more than minimal harm
2025-04-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-28
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-28
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-28
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 2025-05-28
D · Potential for more than minimal harm
2025-04-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-28
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-05-28
B · Minimal harm
2025-04-28
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-28
B · Minimal harm
2025-04-28
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-05-28
B · Minimal harm
2025-04-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-28
B · Minimal harm
2025-04-28
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-03-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-17
B · Minimal harm
2025-03-18
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 2025-04-17
D · Potential for more than minimal harm
2024-07-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-05-28
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 2024-06-28
E · Potential for more than minimal harm
2023-12-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-07
E · Potential for more than minimal harm
2023-12-07
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 2024-01-07
E · Potential for more than minimal harm
2023-12-07
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 2024-01-07
D · Potential for more than minimal harm
2023-12-07
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
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 2024-01-07
D · Potential for more than minimal harm
2023-12-07
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 2024-01-07
D · Potential for more than minimal harm
2023-12-07
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 2024-01-07
D · Potential for more than minimal harm
2023-12-07
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
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 2024-01-07
D · Potential for more than minimal harm
2023-12-07
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
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 2024-01-07
D · Potential for more than minimal harm
2023-12-07
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 2024-01-07
D · Potential for more than minimal harm
2023-12-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-12-07
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-01-07
B · Minimal harm
2023-12-07
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-01-07
B · Minimal harm
2023-12-07
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-01-07
B · Minimal harm
2023-12-07
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 2024-01-07
B · Minimal harm
2023-12-07
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-01-07
B · Minimal harm
2023-12-07
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-01-07
D · Potential for more than minimal harm
2023-11-09
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 2023-12-08
D · Potential for more than minimal harm
2023-08-29
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-29
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-07-05
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-14
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 2023-07-07
D · Potential for more than minimal harm
2023-06-14
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 2023-07-07
F · Potential for more than minimal harm
2021-11-16
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 2021-12-15
E · Potential for more than minimal harm
2021-11-16
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 2021-12-15
E · Potential for more than minimal harm
2021-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-11-16
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 2021-12-15
D · Potential for more than minimal harm
2021-11-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-11-16
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-11-16
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 2021-12-15
D · Potential for more than minimal harm
2021-11-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-11-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-11-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-11-16
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 2021-12-15
D · Potential for more than minimal harm
2021-11-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-11-16
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-11-16
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2021-12-15
D · Potential for more than minimal harm
2021-11-16
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 2021-12-15
D · Potential for more than minimal harm
2021-11-16
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-12-15
B · Minimal harm
2021-11-16
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2021-12-15
Penalties and ownership
What sits behind the stars
Ownership
Abby Gl LLC
Limited Partnership Interest · Organization
Fullerton Wellness Gp, LLC
Limited Partnership Interest · Organization
Lynch, Jose
Operational/Managerial Control · Individual
Lynch, Jose
Corporate Officer · Individual
Pierson, Michael
Operational/Managerial Control · Individual
Rechnitz, Shlomo
Limited Partnership Interest · Individual
Yoon, Stephen
Operational/Managerial Control · Individual
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