Seal Beach Health And Rehabilitation Center
For profit - Limited Liability company · 3000 N Gate Road, Seal Beach, CA 90740 · See home’s Medicare page
Affiliated With Cambridge Healthcare Services
             People or companies with an ownership interest in or managerial control of this home, according to  CMS data.
         3.86
             Nurse hours/resident/day
            
               Reported total nurse staffing hours per resident per day.
            
            State Average: 4.5
         40.3%
             Nurse turnover
            The percentage of nursing staff who stopped working at the home over a 12-month period.
            State Average: 38.9%
         198
             Certified beds
            Qualifying beds in the certified provider or supplier facility. 
         187
             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
                  
                     Ag Facilities Operations, Llc (100%)
                  
               
          Indirect owners
                  
                     Ira E Smedra Living Trust (48%)
Win Win Enterprises, Llc (48%)
Bh Alliance (5%)
                  
               
         Win Win Enterprises, Llc (48%)
Bh Alliance (5%)
 Managerial control
               
                      Ira Smedra since Aug, 2003
Jacob Wintner since Aug, 2003
               
               
         Jacob Wintner since Aug, 2003
 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.
   
         167 
         
      total deficiencies
         11 
         
               
                  
            
         
         
      
   infection-related deficiencies
This home violated federal standards protecting residents from the spread of infections.
               
               Apr 22, 2025
               
               
            
            
                  26 deficiencies 
               
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         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
                  
                  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
                  
                  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 — 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 — 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
                  
                  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 — 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
                  
                  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
                  
                  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
                  
                  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
                  
                  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
                  
                  Administration Deficiency — F0849
                  
                     Failure to: 
                     Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
                  
               
                     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 — 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
                  
                  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
                  
                  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
                  
                  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
                  
                  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
                  
                  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
                  
                  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
                  
                  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 potential for 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 potential for minimal harm
                  
                     Scope
                  
                  Some 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 potential for minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0583
                  
                     Failure to: 
                     Keep residents' personal and medical records private and confidential.
                  
               
                     Severity
                  
                  No actual harm, with potential for 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 potential for minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Mar 6, 2025
               
               
            
            
                  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
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Dec 31, 2024
               
               
            
            
                  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
                  
                  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
                  
                  
               
               Oct 24, 2024
               
               
            
            
                  3 deficiencies 
               
            
               
                  
                  to
                  D
                  
               
            
            
            
         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
                  
                  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 potential for 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 potential for minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Aug 21, 2024
               
               
            
            
                  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
                  
                  
               
               Jul 25, 2024
               
               
            
            
                  2 deficiencies 
               
            Resident Rights Deficiency — F0558
                  
                     Failure to: 
                     Reasonably accommodate the needs and preferences of each resident.
                  
               
                     Severity
                  
                  No actual harm, with potential for 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 potential for minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Jun 21, 2024
               
               
            
            
                  3 deficiencies 
               
               
            
               
                  
                  to
                  D
                  
               
            
            
            
         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
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0553
                  
                     Failure to: 
                     Allow resident to participate in the development and implementation of his or her person-centered plan of care.
                  
               
                     Severity
                  
                  No actual harm, with potential for 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 potential for minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               May 16, 2024
               
               
            
            
                  4 deficiencies 
               
            
               
                  
                  to
                  D
                  
               
            
            
            
         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 — 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
                  
                  Pharmacy Service Deficiency — F0757
                  
                     Failure to: 
                     Ensure each resident's drug regimen must be free from unnecessary drugs.
                  
               
                     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 potential for minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Apr 12, 2024
               
               
            
            
                  1 deficiency 
               
            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
                  
                  
               
               Feb 15, 2024
               
               
            
            
                  1 deficiency 
               
            Resident Rights Deficiency — F0622
                  
                     Failure to: 
                     Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information  when a resident is transferred or discharged.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Feb 1, 2024
               
               
            
            
                  3 deficiencies 
               
            
               
                  
                  to
                  D
                  
               
            
            
            
         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
                  
                  Pharmacy Service Deficiency — F0757
                  
                     Failure to: 
                     Ensure each resident's drug regimen must be free from unnecessary drugs.
                  
               
                     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 potential for minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Jan 9, 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
                  
                  
               
               Nov 29, 2023
               
               
            
            
                  3 deficiencies 
               
            Resident Rights Deficiency — F0559
                  
                     Failure to: 
                     Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
                  
               
                     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 — 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
                  
                  
               
               Oct 30, 2023
               
               
            
            
                  1 deficiency 
               
            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
                  
                  
               
               Aug 23, 2023
               
               
            
            
                  4 deficiencies 
               
            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
                  
                  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
                  
                  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
                  
                  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
                  
                  
               
               Aug 14, 2023
               
               
            
            
                  7 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
                  
                  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
                  
                  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 — 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
                  
                  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
                  
                  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
                  
                  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
                  
                  
               
               Jul 14, 2023
               
               
            
            
                  6 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 — 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 — 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
                  
                  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 — 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
                  
                  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
                  
                  
               
               Jun 29, 2023
               
               
            
            
                  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
                  
                  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
                  
                  
               
               Jun 29, 2023
               
               
            
            
                  34 deficiencies 
               
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         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 — F0802
                  
                     Failure to: 
                     Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
                  
               
                     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
                  
                  Environmental Deficiency — F0909
                  
                     Failure to: 
                     Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some 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
                  
                  Some 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 — 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 — 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
                  
                  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 — 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 — 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
                  
                  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
                  
                  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 — F0700
                  
                     Failure to: 
                     Try different approaches before using a bed rail.  If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
                  
               
                     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 — 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 — 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
                  
                  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
                  
                  Environmental Deficiency — F0908
                  
                     Failure to: 
                     Keep all essential equipment working safely.
                  
               
                     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
                  
                  Environmental Deficiency — F0925
                  
                     Failure to: 
                     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few 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
                  
                  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
                  
                  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
                  
                  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
                  
                  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
                  
                  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 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 — 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
                  
                  Infection Control Deficiency — F0881
                  
                     Failure to: 
                     Implement a program that monitors antibiotic use.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0814
                  
                     Failure to: 
                     Dispose of garbage and refuse properly.
                  
               
                     Severity
                  
                  No actual harm, with potential for minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0582
                  
                     Failure to: 
                     Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
                  
               
                     Severity
                  
                  No actual harm, with potential for minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Jun 23, 2023
               
               
            
            
                  2 deficiencies 
               
            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 — 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
                  
                  
               
               Jun 13, 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
                  
                  
               
               May 15, 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
                  
                  
               
               May 2, 2023
               
               
            
            
                  4 deficiencies 
               
            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
                  
                  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
                  
                  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
                  
                  
               
               Apr 28, 2023
               
               
            
            
                  2 deficiencies 
               
            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 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 21, 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
                  
                  
               
               Apr 19, 2023
               
               
            
            
                  2 deficiencies 
               
            Resident Assessment and Care Planning Deficiency — F0661
                  
                     Failure to: 
                     Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
                  
               
                     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
                  
                  
               
               Apr 12, 2023
               
               
            
            
                  2 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         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
                  
                  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
                  
                  
               
               Apr 11, 2023
               
               
            
            
                  2 deficiencies 
               
               
            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
                  
                  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
                  
                  
               
               Apr 10, 2023
               
               
            
            
                  3 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 — F0661
                  
                     Failure to: 
                     Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
                  
               
                     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
                  
                  
               
               Feb 2, 2023
               
               
            
            
                  2 deficiencies 
               
            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 — 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
                  
                  
               
               Jan 27, 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
                  
                  
               
               Dec 28, 2022
               
               
            
            
                  6 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
                  
                  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
                  
                  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
                  
                  Few people affected
                  
                     Seriousness
                  
                  Administration Deficiency — F0849
                  
                     Failure to: 
                     Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
                  
               
                     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
                  
                  
               
               Dec 1, 2022
               
               
            
            
                  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
                  
                  
               
               Nov 23, 2022
               
               
            
            
                  1 deficiency 
               
            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
                  
                  
               
               Nov 9, 2022
               
               
            
            
                  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
                  
                  
               
               Oct 5, 2022
               
               
            
            
                  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
                  
                  
               
               Sep 9, 2022
               
               
            
            
                  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
                  
                  
               
               Sep 8, 2022
               
               
            
            
                  2 deficiencies 
               
            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
                  
                  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
                  
                  
               
               Sep 7, 2022
               
               
            
            
                  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
                  
                  
               
               Aug 23, 2022
               
               
            
            
                  1 deficiency 
               
            Administration Deficiency — F0773
                  
                     Failure to: 
                     Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Aug 19, 2022
               
               
            
            
                  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
                  
                  
               
               Aug 9, 2022
               
               
            
            
                  1 deficiency 
               
            Resident Assessment and Care Planning Deficiency — F0660
                  
                     Failure to: 
                     Plan the resident's discharge to meet the resident's goals and needs.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Jul 14, 2022
               
               
            
            
                  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
                  
                  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
                  
                  
               
               Jul 7, 2022
               
               
            
            
                  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
                  
                  
               
               May 12, 2021
               
               
            
            
                  18 deficiencies 
               
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Resident Rights Deficiency — F0565
                  
                     Failure to: 
                     Honor the resident's right to organize and participate in resident/family groups in the facility.
                  
               
                     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
                  
                  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
                  
                  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 — 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
                  
                  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
                  
                  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 — F0700
                  
                     Failure to: 
                     Try different approaches before using a bed rail.  If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
                  
               
                     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 — 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
                  
                  Pharmacy Service Deficiency — F0758
                  
                     Failure to: 
                     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few 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
                  
                  Few people affected
                  
                     Seriousness
                  
                  Infection Control Deficiency — F0881
                  
                     Failure to: 
                     Implement a program that monitors antibiotic use.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few 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
                  
                  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
                  
                  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
                  
                  Nutrition and Dietary Deficiency — F0814
                  
                     Failure to: 
                     Dispose of garbage and refuse properly.
                  
               
                     Severity
                  
                  No actual harm, with potential for 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.
   
         $3,145 
         
   total fines
               
               Jun 5, 2023
               
            
            
               
               $3,145  fine