Santa Rosa Post Acute
For profit - Limited Liability company · 4650 Hoen Avenue, Santa Rosa, CA 95405 · See home’s Medicare page
Affiliated With Pacs Group
             People or companies with an ownership interest in or managerial control of this home, according to  CMS data.
         4.02
             Nurse hours/resident/day
            
               Reported total nurse staffing hours per resident per day.
            
            State Average: 4.5
         43.9%
             Nurse turnover
            The percentage of nursing staff who stopped working at the home over a 12-month period.
            State Average: 38.9%
         99
             Certified beds
            Qualifying beds in the certified provider or supplier facility. 
         95
             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
                  
                     Providence Group Wine Country Llc (100%)
                  
               
          Indirect owners
                  
                     Pacs Group, Inc. 
Pacs Holdings, Llc
Providence Group Nh, Llc
Mark Hancock
Jason Murray
                  
               
         Pacs Holdings, Llc
Providence Group Nh, Llc
Mark Hancock
Jason Murray
 Managerial control
               
                      Kevan Bills since Feb, 2022
               
               
          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.
   
         81 
         
      total deficiencies
         5 
         
               
                  
            
         
         
      
   infection-related deficiencies
This home violated federal standards protecting residents from the spread of infections.
               
               May 2, 2025
               
               
            
            
                  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
                  
                  Many people affected
                  
                     Seriousness
                  
                  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
                  
                  Many people affected
                  
                     Seriousness
                  
                  
               
               Apr 25, 2025
               
               
            
            
                  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
                  
                  
               
               Apr 9, 2025
               
               
            
            
                  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
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Mar 24, 2025
               
               
            
            
                  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
                  
                  
               
               Feb 24, 2025
               
               
            
            
                  1 deficiency 
               
            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
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Jan 28, 2025
               
               
            
            
                  1 deficiency 
               
            Quality of Life and Care Deficiency — F0678
                  
                     Failure to: 
                     Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident's advance directives.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Dec 5, 2024
               
               
            
            
                  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
                  
                  Many people affected
                  
                     Seriousness
                  
                  
               
               Oct 4, 2024
               
               
            
            
                  2 deficiencies 
               
            Resident Rights Deficiency — F0576
                  
                     Failure to: 
                     Ensure residents have reasonable access to and privacy in their use of communication methods.
                  
               
                     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 28, 2024
               
               
            
            
                  1 deficiency 
               
            Resident Rights Deficiency — F0576
                  
                     Failure to: 
                     Ensure residents have reasonable access to and privacy in their use of communication methods.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Aug 6, 2024
               
               
            
            
                  1 deficiency 
               
            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
                  
                  
               
               Apr 10, 2024
               
               
            
            
                  4 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Resident Assessment and Care Planning Deficiency — F0655
                  
                     Failure to: 
                     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
                  
               
                     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 — F0800
                  
                     Failure to: 
                     Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0801
                  
                     Failure to: 
                     Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Jan 24, 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
                  
                  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
                  
                  
               
               Jan 3, 2024
               
               
            
            
                  1 deficiency 
               
            Administration Deficiency — F0839
                  
                     Failure to: 
                     Employ staff that are licensed, certified, or registered in accordance with state laws.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Dec 22, 2023
               
               
            
            
                  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
                  
                  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
                  
                  
               
               Dec 15, 2023
               
               
            
            
                  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 14, 2023
               
               
            
            
                  1 deficiency 
               
            Environmental Deficiency — F0908
                  
                     Failure to: 
                     Keep all essential equipment working safely.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Nov 2, 2023
               
               
            
            
                  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
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Sep 28, 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
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Jun 22, 2023
               
               
            
            
                  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
                  
                  
               
               Jun 20, 2023
               
               
            
            
                  2 deficiencies 
               
            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
                  
                  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 24, 2023
               
               
            
            
                  2 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Resident Assessment and Care Planning Deficiency — F0655
                  
                     Failure to: 
                     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some 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
                  
                  
               
               Apr 12, 2023
               
               
            
            
                  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
                  
                  
               
               Mar 14, 2023
               
               
            
            
                  2 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         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
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Mar 1, 2023
               
               
            
            
                  2 deficiencies 
               
               
            
               
                  
                  to
                  G
                  
               
            
            
            
         Quality of Life and Care Deficiency — F0684
                  
                     Failure to: 
                     Provide appropriate treatment and care according to orders, resident's preferences and goals.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few 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
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Feb 28, 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
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Feb 14, 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
                  
                  
               
               Jan 4, 2023
               
               
            
            
                  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
                  
                  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
                  
                  
               
               Dec 23, 2022
               
               
            
            
                  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
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Dec 21, 2022
               
               
            
            
                  2 deficiencies 
               
            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
                  
                  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 19, 2022
               
               
            
            
                  2 deficiencies 
               
            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
                  
                  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
                  
                  
               
               Oct 13, 2022
               
               
            
            
                  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
                  
                  Many people affected
                  
                     Seriousness
                  
                  
               
               Oct 5, 2022
               
               
            
            
                  4 deficiencies 
               
            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
                  
                  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
                  
                  Nursing and Physician Services Deficiency — F0726
                  
                     Failure to: 
                     Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Nursing and Physician Services Deficiency — F0730
                  
                     Failure to: 
                     Observe each nurse aide's job performance and give regular training.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Sep 23, 2022
               
               
            
            
                  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
                  
                  
               
               Aug 3, 2022
               
               
            
            
                  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
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Apr 23, 2021
               
               
            
            
                  9 deficiencies 
               
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Resident Rights Deficiency — F0623
                  
                     Failure to: 
                     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0575
                  
                     Failure to: 
                     Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
                  
               
                     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 — F0679
                  
                     Failure to: 
                     Provide activities to meet all resident's needs.
                  
               
                     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
                  
                  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
                  
                  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
                  
                  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
                  
                  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
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Mar 28, 2019
               
               
            
            
                  20 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
                  
                  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
                  
                  Actual harm that is not immediate jeopardy
                  
                     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
                  
                  Many 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
                  
                  Many people affected
                  
                     Seriousness
                  
                  Administration Deficiency — F0867
                  
                     Failure to: 
                     Set up an ongoing quality assessment and assurance group to review quality deficiencies  and develop corrective plans of action.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Many 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 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
                  
                  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
                  
                  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
                  
                  Quality of Life and Care Deficiency — F0741
                  
                     Failure to: 
                     Ensure that the facility has sufficient staff members who possess the  competencies and skills to meet the behavioral health needs of residents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some 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
                  
                  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
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0801
                  
                     Failure to: 
                     Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0744
                  
                     Failure to: 
                     Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
                  
               
                     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
                  
                  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
                  
                  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
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0688
                  
                     Failure to: 
                     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0655
                  
                     Failure to: 
                     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
                  
               
                     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
                  
                  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.
   
         $13K 
         
      total fines
         1 
         
   payment suspension