Cycle 1
Health 2025-02-16 · Fire 2025-02-16
17 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Los Angeles, CA
Vista Del Sol Care Center
2-star overall rating with 2-star inspections with $116,475 in total fines with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
11620 West Washington Blvd, Los Angeles, CA
(310) 390-9045
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
50
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-04-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.37
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.35
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.12
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.85
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.60
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.33
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
0.35
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,535
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9894
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.81
Baseline 21.17% · Performance 19.20% · Measure score 4.81 · Achievement 4.81 · Improvement 4.24
Healthcare-associated infections
0
Baseline 7.17% · Performance 7.73% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.61
Baseline 31.37% · Performance 44.83% · Measure score 4.61 · Achievement 4.61 · Improvement 0
Adjusted total nurse staffing
4.93
Baseline 6.28 hours · Performance 4.48 hours · Measure score 4.93 · Achievement 4.93 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.54% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 115 · Observed rate 9.57% · Lower 95% interval 7.23% |
| Discharge to community | 35.82% |
50.57%
14.8 pts worse
|
Worse than the National Rate · Eligible stays 86 · Observed rate 26.74% · Lower 95% interval 26.89% |
| Medicare spending per beneficiary | 1.83 |
1.02
0.8 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 77 · Denominator 77 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 77 |
| Discharge self-care score | 38% |
53.69%
15.7 pts worse
|
Numerator 19 · Denominator 50 |
| Discharge mobility score | 36% |
50.94%
14.9 pts worse
|
Numerator 18 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 1.3% |
2.29%
1 pts better
|
Numerator 1 · Denominator 77 · Adjusted rate 0.96% |
| Healthcare-associated infections requiring hospitalization | 7.73% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 8.54% · Lower 95% interval 4.08% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 35 · Denominator 35 |
| Discharge function score | 40% |
56.45%
16.5 pts worse
|
Numerator 20 · Denominator 50 |
| Transfer of health information to provider | 73.91% |
95.95%
22 pts worse
|
Numerator 17 · Denominator 23 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 74.36% |
25.2%
49.2 pts better
|
Numerator 29 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.3
0.4 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.2 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
98.5%
6.8 pts worse
|
93.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 92.5% · Q3 91.9% · Q4 91.9% · 4Q avg 91.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
1.6%
1 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 26.5% |
6.8%
19.7 pts worse
|
11.4%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 27.8% · Q3 9.1% · Q4 33.3% · 4Q avg 26.5% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
4.1%
2.1 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 3.7% · Q3 5.9% · Q4 6.1% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.8% |
13.7%
1.1 pts worse
|
19.6%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 12.5% · Q3 13.9% · Q4 18.9% · 4Q avg 14.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.3% |
14.2%
11.1 pts worse
|
16.7%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 23.8% · Q3 17.4% · Q4 28.0% · 4Q avg 25.3% · 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 | 23.5% |
11.0%
12.5 pts worse
|
16.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.7% |
10.7%
15 pts worse
|
14.9%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 41.7% · Q3 12.1% · Q4 28.6% · 4Q avg 25.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.0%
0.3 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.2%
0.4 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
10.9%
6.8 pts worse
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 18.8% · Q3 19.0% · Q4 13.9% · 4Q avg 17.7% |
| 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 4.0% · Q2 2.4% · Q3 3.2% · Q4 5.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.7% |
94.0%
34.3 pts worse
|
81.7%
22 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 41.7% · Q4 80.0% · 4Q avg 59.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.3% |
11.2%
5.9 pts better
|
12.0%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.3% · Observed 5.6% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.7% |
23.2%
7.5 pts better
|
23.9%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 16.7% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-25 · Fire 2024-03-25
26 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
19 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Cycle 3
Health 2022-02-06 · Fire 2022-02-06
33 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-16
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 2025-03-05
D · Potential for more than minimal harm
2025-02-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-16
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 2025-03-05
F · Potential for more than minimal harm
2024-03-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-27
F · Potential for more than minimal harm
2024-03-25
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-04-27
F · Potential for more than minimal harm
2024-03-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-27
F · Potential for more than minimal harm
2024-03-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-27
E · Potential for more than minimal harm
2024-03-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-27
E · Potential for more than minimal harm
2024-03-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-27
E · Potential for more than minimal harm
2024-03-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-27
E · Potential for more than minimal harm
2024-03-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-27
D · Potential for more than minimal harm
2024-03-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-27
D · Potential for more than minimal harm
2024-03-25
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-04-27
D · Potential for more than minimal harm
2024-03-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-27
D · Potential for more than minimal harm
2024-03-25
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 2024-04-27
D · Potential for more than minimal harm
2024-03-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-27
C · Minimal harm
2024-03-25
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-04-27
C · Minimal harm
2024-03-25
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-04-27
C · Minimal harm
2024-03-25
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-04-27
C · Minimal harm
2024-03-25
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-04-27
C · Minimal harm
2024-03-25
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-27
C · Minimal harm
2024-03-25
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-04-27
F · Potential for more than minimal harm
2022-02-06
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-03-05
F · Potential for more than minimal harm
2022-02-06
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2022-03-05
F · Potential for more than minimal harm
2022-02-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-03-05
F · Potential for more than minimal harm
2022-02-06
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 2022-03-05
F · Potential for more than minimal harm
2022-02-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-03-05
F · Potential for more than minimal harm
2022-02-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-03-05
F · Potential for more than minimal harm
2022-02-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-03-05
F · Potential for more than minimal harm
2022-02-06
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-03-05
F · Potential for more than minimal harm
2022-02-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-03-05
F · Potential for more than minimal harm
2022-02-06
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-03-05
F · Potential for more than minimal harm
2022-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-05
F · Potential for more than minimal harm
2022-02-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-05
F · Potential for more than minimal harm
2022-02-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-03-05
F · Potential for more than minimal harm
2022-02-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-03-05
F · Potential for more than minimal harm
2022-02-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-03-05
D · Potential for more than minimal harm
2022-02-06
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2022-03-05
C · Minimal harm
2022-02-06
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-03-05
C · Minimal harm
2022-02-06
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-03-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-14
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 2025-12-10
D · Potential for more than minimal harm
2025-09-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-09-16
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 2025-10-24
D · Potential for more than minimal harm
2025-06-23
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 2025-07-09
D · Potential for more than minimal harm
2025-04-10
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 2025-04-25
D · Potential for more than minimal harm
2025-04-10
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 2025-04-25
E · Potential for more than minimal harm
2025-02-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-02-16
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 2025-03-13
E · Potential for more than minimal harm
2025-02-16
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-02-16
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-02-16
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-16
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 2025-03-13
D · Potential for more than minimal harm
2025-02-16
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 2025-03-13
D · Potential for more than minimal harm
2025-02-16
F713 · Nursing and Physician Services Deficiencies
Health
Provide or arrange emergency care by a doctor 24 hours a day.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-16
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 2025-03-13
D · Potential for more than minimal harm
2025-02-16
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 2025-03-13
B · Minimal harm
2025-02-16
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-03-13
E · Potential for more than minimal harm
2024-10-09
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-10-31
G · Actual harm
2024-03-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-22
G · Actual harm
2024-03-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-03-25
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 2024-04-22
E · Potential for more than minimal harm
2024-03-25
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 2024-04-22
E · Potential for more than minimal harm
2024-03-25
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 2024-04-22
E · Potential for more than minimal harm
2024-03-25
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 2024-04-22
E · Potential for more than minimal harm
2024-03-25
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-04-22
E · Potential for more than minimal harm
2024-03-25
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 2024-04-22
E · Potential for more than minimal harm
2024-03-25
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 2024-04-22
E · Potential for more than minimal harm
2024-03-25
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 2024-04-22
D · Potential for more than minimal harm
2024-03-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-25
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-25
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-25
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-25
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 2024-04-22
D · Potential for more than minimal harm
2024-03-25
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 2024-04-22
D · Potential for more than minimal harm
2024-03-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-25
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 2024-04-22
D · Potential for more than minimal harm
2024-03-25
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 2024-04-22
D · Potential for more than minimal harm
2024-03-25
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-25
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-01-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-26
E · Potential for more than minimal harm
2023-11-17
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-12-12
G · Actual harm
2023-05-17
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 2023-06-17
F · Potential for more than minimal harm
2023-05-17
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 2023-06-17
G · Actual harm
2023-04-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-03-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-24
E · Potential for more than minimal harm
2022-02-06
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-03-07
E · Potential for more than minimal harm
2022-02-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-03-07
E · Potential for more than minimal harm
2022-02-06
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2022-03-07
E · Potential for more than minimal harm
2022-02-06
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2022-03-07
E · Potential for more than minimal harm
2022-02-06
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-03-07
E · Potential for more than minimal harm
2022-02-06
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 2022-03-07
E · Potential for more than minimal harm
2022-02-06
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 2022-03-07
E · Potential for more than minimal harm
2022-02-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-03-07
E · Potential for more than minimal harm
2022-02-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-03-07
E · Potential for more than minimal harm
2022-02-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-03-07
E · Potential for more than minimal harm
2022-02-06
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 2022-03-07
E · Potential for more than minimal harm
2022-02-06
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 2022-03-07
E · Potential for more than minimal harm
2022-02-06
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 2022-03-07
E · Potential for more than minimal harm
2022-02-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-03-07
E · Potential for more than minimal harm
2022-02-06
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 2022-03-07
E · Potential for more than minimal harm
2022-02-06
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 2022-03-07
E · Potential for more than minimal harm
2022-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-07
E · Potential for more than minimal harm
2022-02-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-03-07
D · Potential for more than minimal harm
2022-02-06
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-03-07
D · Potential for more than minimal harm
2022-02-06
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 2022-03-07
D · Potential for more than minimal harm
2022-02-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-03-07
D · Potential for more than minimal harm
2022-02-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-03-07
D · Potential for more than minimal harm
2022-02-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-03-07
D · Potential for more than minimal harm
2022-02-06
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2022-03-07
D · Potential for more than minimal harm
2022-02-06
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-03-07
B · Minimal harm
2022-02-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-03-07
B · Minimal harm
2022-02-06
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2022-05-23
Penalties and ownership
What sits behind the stars
$110,124
2024-03-25
Fine
Fine · fine $110,124
Fine
$0
2024-03-25
Payment Denial
Payment Denial · denial start 2024-04-23 · 4 days
4 day denial
$6,351
2023-08-28
Fine
Fine · fine $6,351
Fine
Ownership
Jacobs, Dov
5% Or Greater Direct Ownership Interest · Individual
Jacobs, Dov
Corporate Director · Individual
Valdivia, Rosa
Operational/Managerial Control · Individual
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