Santa Anita Convalescent Hospital
For profit - Corporation · 5522 Gracewood Ave., Temple City, CA 91780 · See home’s Medicare page
Special Focus Facility Candidate
            Has a history of serious quality issues but has not been formally flagged by the government.
         4.09
             Nurse hours/resident/day
            
               Reported total nurse staffing hours per resident per day.
            
            State Average: 4.5
         50.6%
             Nurse turnover
            The percentage of nursing staff who stopped working at the home over a 12-month period.
            State Average: 38.9%
         391
             Certified beds
            Qualifying beds in the certified provider or supplier facility. 
         370
             Average residents/day
            Average number of residents based on daily census.
         Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
          Direct owners
                  
                     Golden State Health Centers, Inc. (100%)
                  
               
          Indirect owners
                  
                      Howard Weiss (23%)
Martin Weiss (21%)
Helene Mayer 2007 Irrevocable Trust (20%)
The Chani Levitin Gst Non Exempt Trust (18%)
                  
               
         Martin Weiss (21%)
Helene Mayer 2007 Irrevocable Trust (20%)
The Chani Levitin Gst Non Exempt Trust (18%)
 Managerial control
               
                  No information available
               
               
          Managing employee(s)
               
                  No information available
               
               
         Inspection Reports
Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
   
         182 
         
      total deficiencies
         11 
         
               
                  
            
         
         
      
   infection-related deficiencies
This home violated federal standards protecting residents from the spread of infections.
               
               May 8, 2025
               
               
            
            
                  25 deficiencies 
               
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Nutrition and Dietary Deficiency — F0814
                  
                     Failure to: 
                     Dispose of garbage and refuse properly.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0755
                  
                     Failure to: 
                     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0759
                  
                     Failure to: 
                     Ensure medication error rates are not 5 percent or greater.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Infection Control Deficiency — F0880
                  
                     Failure to: 
                     Provide and implement an infection prevention and control program.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0761
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Freedom from Abuse, Neglect, and Exploitation Deficiency — F0605
                  
                     Failure to: 
                     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0677
                  
                     Failure to: 
                     Provide care and assistance to perform activities of daily living for any resident who is unable.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0812
                  
                     Failure to: 
                     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0813
                  
                     Failure to: 
                     Have a policy regarding use and storage of foods brought to residents by family and other visitors.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0842
                  
                     Failure to: 
                     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Administration Deficiency — F0848
                  
                     Failure to: 
                     Provide a neutral and fair arbitration process and agree to arbitrator and venue.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Environmental Deficiency — F0921
                  
                     Failure to: 
                     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
                  
                     Failure to: 
                     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0686
                  
                     Failure to: 
                     Provide appropriate pressure ulcer care and prevent new ulcers from developing.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0806
                  
                     Failure to: 
                     Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0558
                  
                     Failure to: 
                     Reasonably accommodate the needs and preferences of each resident.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0584
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0641
                  
                     Failure to: 
                     Ensure each resident receives an accurate assessment.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0657
                  
                     Failure to: 
                     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0693
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0698
                  
                     Failure to: 
                     Provide safe, appropriate dialysis care/services for a resident who requires such services.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0740
                  
                     Failure to: 
                     Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0550
                  
                     Failure to: 
                     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Environmental Deficiency — F0912
                  
                     Failure to: 
                     Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
                  
               
                     Severity
                  
                  No actual harm, with potential for minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Apr 16, 2025
               
               
            
            
                  2 deficiencies 
               
            Quality of Life and Care Deficiency — F0690
                  
                     Failure to: 
                     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care,  and appropriate care  to prevent urinary tract infections.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Administration Deficiency — F0770
                  
                     Failure to: 
                     Provide timely, quality laboratory services/tests to meet the needs of residents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Apr 3, 2025
               
               
            
            
                  2 deficiencies 
               
            
               
                  
                  to
                  D
                  
               
            
            
            
         Quality of Life and Care Deficiency — F0677
                  
                     Failure to: 
                     Provide care and assistance to perform activities of daily living for any resident who is unable.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Nursing and Physician Services Deficiency — F0732
                  
                     Failure to: 
                     Post nurse staffing information every day.
                  
               
                     Severity
                  
                  No actual harm, with potential for minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Feb 27, 2025
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0684
                  
                     Failure to: 
                     Provide appropriate treatment and care according to orders, resident's preferences and goals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Feb 25, 2025
               
               
            
            
                  2 deficiencies 
               
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Infection Control Deficiency — F0880
                  
                     Failure to: 
                     Provide and implement an infection prevention and control program.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0550
                  
                     Failure to: 
                     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Feb 21, 2025
               
               
            
            
                  1 deficiency 
               
            Resident Assessment and Care Planning Deficiency — F0658
                  
                     Failure to: 
                     Ensure services provided by the nursing facility meet professional standards of quality.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Jan 29, 2025
               
               
            
            
                  3 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Pharmacy Service Deficiency — F0761
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0573
                  
                     Failure to: 
                     Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0686
                  
                     Failure to: 
                     Provide appropriate pressure ulcer care and prevent new ulcers from developing.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Jan 8, 2025
               
               
            
            
                  3 deficiencies 
               
            
               
                  
                  to
                  G
                  
               
            
            
            
         Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0686
                  
                     Failure to: 
                     Provide appropriate pressure ulcer care and prevent new ulcers from developing.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Environmental Deficiency — F0921
                  
                     Failure to: 
                     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Oct 18, 2024
               
               
            
            
                  2 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Quality of Life and Care Deficiency — F0684
                  
                     Failure to: 
                     Provide appropriate treatment and care according to orders, resident's preferences and goals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
                  
                     Failure to: 
                     Develop and implement policies and procedures to prevent abuse, neglect, and theft.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Sep 26, 2024
               
               
            
            
                  3 deficiencies 
               
            Resident Rights Deficiency — F0558
                  
                     Failure to: 
                     Reasonably accommodate the needs and preferences of each resident.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Freedom from Abuse, Neglect, and Exploitation Deficiency — F0604
                  
                     Failure to: 
                     Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0657
                  
                     Failure to: 
                     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Sep 25, 2024
               
               
            
            
                  3 deficiencies 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0602
                  
                     Failure to: 
                     Protect each resident from the wrongful use of the resident's belongings or money.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0676
                  
                     Failure to: 
                     Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0692
                  
                     Failure to: 
                     Provide enough food/fluids to maintain a resident's health.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Sep 19, 2024
               
               
            
            
                  2 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
                  
                     Failure to: 
                     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Sep 4, 2024
               
               
            
            
                  2 deficiencies 
               
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Infection Control Deficiency — F0880
                  
                     Failure to: 
                     Provide and implement an infection prevention and control program.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0658
                  
                     Failure to: 
                     Ensure services provided by the nursing facility meet professional standards of quality.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Aug 26, 2024
               
               
            
            
                  1 deficiency 
               
            Resident Assessment and Care Planning Deficiency — F0657
                  
                     Failure to: 
                     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Aug 16, 2024
               
               
            
            
                  6 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Quality of Life and Care Deficiency — F0695
                  
                     Failure to: 
                     Provide safe and appropriate respiratory care for a resident when needed.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0842
                  
                     Failure to: 
                     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0550
                  
                     Failure to: 
                     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0656
                  
                     Failure to: 
                     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0691
                  
                     Failure to: 
                     Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0755
                  
                     Failure to: 
                     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Aug 14, 2024
               
               
            
            
                  1 deficiency 
               
            Environmental Deficiency — F0919
                  
                     Failure to: 
                     Make sure that a working call system is available in each resident's  bathroom and bathing area.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Aug 9, 2024
               
               
            
            
                  2 deficiencies 
               
            Quality of Life and Care Deficiency — F0676
                  
                     Failure to: 
                     Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Jul 27, 2024
               
               
            
            
                  3 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Pharmacy Service Deficiency — F0761
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
                  
                     Failure to: 
                     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
                  
                     Failure to: 
                     Develop and implement policies and procedures to prevent abuse, neglect, and theft.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               May 25, 2024
               
               
            
            
                  29 deficiencies 
               
               
            
               
                  
                  to
                  G
                  
               
            
            
            
         Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0697
                  
                     Failure to: 
                     Provide safe, appropriate pain management for a resident who requires such services.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0558
                  
                     Failure to: 
                     Reasonably accommodate the needs and preferences of each resident.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0578
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0686
                  
                     Failure to: 
                     Provide appropriate pressure ulcer care and prevent new ulcers from developing.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0690
                  
                     Failure to: 
                     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care,  and appropriate care  to prevent urinary tract infections.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0695
                  
                     Failure to: 
                     Provide safe and appropriate respiratory care for a resident when needed.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0755
                  
                     Failure to: 
                     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0760
                  
                     Failure to: 
                     Ensure that residents are free from significant medication errors.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0761
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0812
                  
                     Failure to: 
                     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0814
                  
                     Failure to: 
                     Dispose of garbage and refuse properly.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Infection Control Deficiency — F0880
                  
                     Failure to: 
                     Provide and implement an infection prevention and control program.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0656
                  
                     Failure to: 
                     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0552
                  
                     Failure to: 
                     Ensure that residents are fully informed and understand their health status, care and treatments.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0550
                  
                     Failure to: 
                     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0657
                  
                     Failure to: 
                     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0756
                  
                     Failure to: 
                     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0583
                  
                     Failure to: 
                     Keep residents' personal and medical records private and confidential.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0584
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0645
                  
                     Failure to: 
                     PASARR screening for Mental disorders or Intellectual Disabilities
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0676
                  
                     Failure to: 
                     Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0677
                  
                     Failure to: 
                     Provide care and assistance to perform activities of daily living for any resident who is unable.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0684
                  
                     Failure to: 
                     Provide appropriate treatment and care according to orders, resident's preferences and goals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0698
                  
                     Failure to: 
                     Provide safe, appropriate dialysis care/services for a resident who requires such services.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0842
                  
                     Failure to: 
                     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0694
                  
                     Failure to: 
                     Provide for the safe, appropriate administration of IV fluids for a resident when needed.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0803
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Environmental Deficiency — F0912
                  
                     Failure to: 
                     Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
                  
               
                     Severity
                  
                  No actual harm, with potential for minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               May 10, 2024
               
               
            
            
                  1 deficiency 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
                  
                     Failure to: 
                     Develop and implement policies and procedures to prevent abuse, neglect, and theft.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Apr 24, 2024
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0677
                  
                     Failure to: 
                     Provide care and assistance to perform activities of daily living for any resident who is unable.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Apr 23, 2024
               
               
            
            
                  2 deficiencies 
               
            Resident Rights Deficiency — F0580
                  
                     Failure to: 
                     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.)  that affect the resident.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0842
                  
                     Failure to: 
                     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Apr 19, 2024
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Apr 14, 2024
               
               
            
            
                  2 deficiencies 
               
            
               
                  
                  to
                  K
                  
               
            
            
            
         Quality of Life and Care Deficiency — F0742
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  Immediate jeopardy to resident health or safety
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
                  
                     Failure to: 
                     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Apr 3, 2024
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0695
                  
                     Failure to: 
                     Provide safe and appropriate respiratory care for a resident when needed.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Mar 13, 2024
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0825
                  
                     Failure to: 
                     Provide or get specialized rehabilitative services as required for a resident.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Mar 6, 2024
               
               
            
            
                  2 deficiencies 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
                  
                     Failure to: 
                     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0656
                  
                     Failure to: 
                     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Feb 13, 2024
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0684
                  
                     Failure to: 
                     Provide appropriate treatment and care according to orders, resident's preferences and goals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Feb 5, 2024
               
               
            
            
                  1 deficiency 
               
            Resident Assessment and Care Planning Deficiency — F0656
                  
                     Failure to: 
                     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Jan 27, 2024
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0686
                  
                     Failure to: 
                     Provide appropriate pressure ulcer care and prevent new ulcers from developing.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Jan 9, 2024
               
               
            
            
                  1 deficiency 
               
            Nutrition and Dietary Deficiency — F0804
                  
                     Failure to: 
                     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Jan 8, 2024
               
               
            
            
                  2 deficiencies 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
                  
                     Failure to: 
                     Develop and implement policies and procedures to prevent abuse, neglect, and theft.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
                  
                     Failure to: 
                     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Dec 27, 2023
               
               
            
            
                  1 deficiency 
               
            Resident Assessment and Care Planning Deficiency — F0656
                  
                     Failure to: 
                     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Dec 6, 2023
               
               
            
            
                  1 deficiency 
               
            Environmental Deficiency — F0921
                  
                     Failure to: 
                     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Nov 15, 2023
               
               
            
            
                  4 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Quality of Life and Care Deficiency — F0676
                  
                     Failure to: 
                     Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0755
                  
                     Failure to: 
                     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Environmental Deficiency — F0919
                  
                     Failure to: 
                     Make sure that a working call system is available in each resident's  bathroom and bathing area.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Oct 13, 2023
               
               
            
            
                  1 deficiency 
               
            Resident Assessment and Care Planning Deficiency — F0656
                  
                     Failure to: 
                     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Oct 6, 2023
               
               
            
            
                  1 deficiency 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
                  
                     Failure to: 
                     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Sep 25, 2023
               
               
            
            
                  1 deficiency 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0604
                  
                     Failure to: 
                     Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Sep 22, 2023
               
               
            
            
                  1 deficiency 
               
            Resident Assessment and Care Planning Deficiency — F0842
                  
                     Failure to: 
                     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Sep 7, 2023
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Aug 1, 2023
               
               
            
            
                  3 deficiencies 
               
            
               
                  
                  to
                  J
                  
               
            
            
            
         Resident Rights Deficiency — F0580
                  
                     Failure to: 
                     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.)  that affect the resident.
                  
               
                     Severity
                  
                  Immediate jeopardy to resident health or safety
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0695
                  
                     Failure to: 
                     Provide safe and appropriate respiratory care for a resident when needed.
                  
               
                     Severity
                  
                  Immediate jeopardy to resident health or safety
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
                  
                     Failure to: 
                     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Jun 30, 2023
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0686
                  
                     Failure to: 
                     Provide appropriate pressure ulcer care and prevent new ulcers from developing.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               May 17, 2023
               
               
            
            
                  25 deficiencies 
               
               
            
               
                  
                  to
                  K
                  
               
            
            
            
         Quality of Life and Care Deficiency — F0698
                  
                     Failure to: 
                     Provide safe, appropriate dialysis care/services for a resident who requires such services.
                  
               
                     Severity
                  
                  Immediate jeopardy to resident health or safety
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nursing and Physician Services Deficiency — F0725
                  
                     Failure to: 
                     Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0686
                  
                     Failure to: 
                     Provide appropriate pressure ulcer care and prevent new ulcers from developing.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0695
                  
                     Failure to: 
                     Provide safe and appropriate respiratory care for a resident when needed.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0761
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0804
                  
                     Failure to: 
                     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0812
                  
                     Failure to: 
                     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0814
                  
                     Failure to: 
                     Dispose of garbage and refuse properly.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Environmental Deficiency — F0919
                  
                     Failure to: 
                     Make sure that a working call system is available in each resident's  bathroom and bathing area.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0842
                  
                     Failure to: 
                     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0697
                  
                     Failure to: 
                     Provide safe, appropriate pain management for a resident who requires such services.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0550
                  
                     Failure to: 
                     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Nursing and Physician Services Deficiency — F0732
                  
                     Failure to: 
                     Post nurse staffing information every day.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0755
                  
                     Failure to: 
                     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Infection Control Deficiency — F0883
                  
                     Failure to: 
                     Develop and implement policies and procedures for flu and pneumonia vaccinations.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0554
                  
                     Failure to: 
                     Allow residents to self-administer drugs if determined clinically appropriate.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0806
                  
                     Failure to: 
                     Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0558
                  
                     Failure to: 
                     Reasonably accommodate the needs and preferences of each resident.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Freedom from Abuse, Neglect, and Exploitation Deficiency — F0604
                  
                     Failure to: 
                     Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0641
                  
                     Failure to: 
                     Ensure each resident receives an accurate assessment.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0645
                  
                     Failure to: 
                     PASARR screening for Mental disorders or Intellectual Disabilities
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0656
                  
                     Failure to: 
                     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0657
                  
                     Failure to: 
                     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Environmental Deficiency — F0912
                  
                     Failure to: 
                     Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
                  
               
                     Severity
                  
                  No actual harm, with potential for minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               May 7, 2023
               
               
            
            
                  2 deficiencies 
               
            Resident Rights Deficiency — F0583
                  
                     Failure to: 
                     Keep residents' personal and medical records private and confidential.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0693
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Apr 24, 2023
               
               
            
            
                  1 deficiency 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
                  
                     Failure to: 
                     Respond appropriately to all alleged violations.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Apr 19, 2023
               
               
            
            
                  1 deficiency 
               
            Resident Assessment and Care Planning Deficiency — F0657
                  
                     Failure to: 
                     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Apr 7, 2023
               
               
            
            
                  3 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Resident Assessment and Care Planning Deficiency — F0656
                  
                     Failure to: 
                     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0697
                  
                     Failure to: 
                     Provide safe, appropriate pain management for a resident who requires such services.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0842
                  
                     Failure to: 
                     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Mar 30, 2023
               
               
            
            
                  1 deficiency 
               
            Resident Rights Deficiency — F0584
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Mar 22, 2023
               
               
            
            
                  2 deficiencies 
               
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Infection Control Deficiency — F0880
                  
                     Failure to: 
                     Provide and implement an infection prevention and control program.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Infection Control Deficiency — F0883
                  
                     Failure to: 
                     Develop and implement policies and procedures for flu and pneumonia vaccinations.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Mar 17, 2023
               
               
            
            
                  2 deficiencies 
               
            Resident Rights Deficiency — F0625
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0626
                  
                     Failure to: 
                     Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Mar 10, 2023
               
               
            
            
                  1 deficiency 
               
            Resident Rights Deficiency — F0557
                  
                     Failure to: 
                     Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Mar 9, 2023
               
               
            
            
                  2 deficiencies 
               
            Quality of Life and Care Deficiency — F0697
                  
                     Failure to: 
                     Provide safe, appropriate pain management for a resident who requires such services.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0755
                  
                     Failure to: 
                     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Mar 8, 2023
               
               
            
            
                  1 deficiency 
               
            Nursing and Physician Services Deficiency — F0712
                  
                     Failure to: 
                     Ensure that the resident and his/her doctor meet face-to-face at all required visits.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Mar 7, 2023
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Feb 8, 2023
               
               
            
            
                  1 deficiency 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
                  
                     Failure to: 
                     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Jan 19, 2023
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0684
                  
                     Failure to: 
                     Provide appropriate treatment and care according to orders, resident's preferences and goals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Dec 27, 2022
               
               
            
            
                  1 deficiency 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
                  
                     Failure to: 
                     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Dec 14, 2022
               
               
            
            
                  1 deficiency 
               
               
            Infection Control Deficiency — F0880
                  
                     Failure to: 
                     Provide and implement an infection prevention and control program.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Dec 6, 2022
               
               
            
            
                  1 deficiency 
               
               
            Infection Control Deficiency — F0880
                  
                     Failure to: 
                     Provide and implement an infection prevention and control program.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Oct 15, 2022
               
               
            
            
                  2 deficiencies 
               
               
            Infection Control Deficiency — F0880
                  
                     Failure to: 
                     Provide and implement an infection prevention and control program.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Infection Control Deficiency — F0885
                  
                     Failure to: 
                     Report COVID19 data to residents and families.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Oct 8, 2022
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Sep 28, 2022
               
               
            
            
                  2 deficiencies 
               
            Resident Rights Deficiency — F0558
                  
                     Failure to: 
                     Reasonably accommodate the needs and preferences of each resident.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0677
                  
                     Failure to: 
                     Provide care and assistance to perform activities of daily living for any resident who is unable.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Sep 19, 2022
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0690
                  
                     Failure to: 
                     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care,  and appropriate care  to prevent urinary tract infections.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Sep 14, 2022
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0695
                  
                     Failure to: 
                     Provide safe and appropriate respiratory care for a resident when needed.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Aug 23, 2022
               
               
            
            
                  1 deficiency 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
                  
                     Failure to: 
                     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Aug 10, 2022
               
               
            
            
                  1 deficiency 
               
            Resident Rights Deficiency — F0550
                  
                     Failure to: 
                     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Aug 5, 2022
               
               
            
            
                  1 deficiency 
               
            Pharmacy Service Deficiency — F0760
                  
                     Failure to: 
                     Ensure that residents are free from significant medication errors.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Penalties
A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
   
         $255K 
         
      total fines
         2 
         
   payment suspensions