Glendora Canyon Transitional Care Unit
For profit - Partnership · 401 W. Ada Ave., Glendora, CA 91741 · See home’s Medicare page
Affiliated With Abraham Bak & Menachem Gastwirth
             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
         31.1%
             Nurse turnover
            The percentage of nursing staff who stopped working at the home over a 12-month period.
            State Average: 38.9%
         120
             Certified beds
            Qualifying beds in the certified provider or supplier facility. 
         111
             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
                  
                     401 West Ada Avenue, Llc (50%)
Foothill Rehab Center, Llc (50%)
                  
               
         Foothill Rehab Center, Llc (50%)
 Indirect owners
                  
                     Abe And Rachel Bak Family Trust 
Bagz Holdings, Llc
Mcp Gv, Llc
Abraham Bak
Menachem Gastwirth
Kenneth Lehmann
                  
               
         Bagz Holdings, Llc
Mcp Gv, Llc
Abraham Bak
Menachem Gastwirth
Kenneth Lehmann
 Managerial control
               
                      Abraham Bak since Jan, 2018
Menachem Gastwirth since Jan, 2018
               
               
         Menachem Gastwirth since Jan, 2018
 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.
   
         82 
         
      total deficiencies
         5 
         
               
                  
            
         
         
      
   infection-related deficiencies
This home violated federal standards protecting residents from the spread of infections.
               
               Mar 21, 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
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Jan 29, 2025
               
               
            
            
                  2 deficiencies 
               
            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 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
                  
                  
               
               Nov 8, 2024
               
               
            
            
                  16 deficiencies 
               
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Resident Rights Deficiency — F0578
                  
                     Failure to: 
                     Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — 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
                  
                  Some 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
                  
                  Some 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
                  
                  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 — F0684
                  
                     Failure to: 
                     Provide appropriate treatment and care according to orders, resident's preferences and goals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0686
                  
                     Failure to: 
                     Provide appropriate pressure ulcer care and prevent new ulcers from developing.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0558
                  
                     Failure to: 
                     Reasonably accommodate the needs and preferences of each resident.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Environmental Deficiency — F0919
                  
                     Failure to: 
                     Make sure that a working call system is available in each resident's  bathroom and bathing area.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0641
                  
                     Failure to: 
                     Ensure each resident receives an accurate assessment.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0655
                  
                     Failure to: 
                     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — 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 — 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
                  
                  Nursing and Physician Services Deficiency — F0732
                  
                     Failure to: 
                     Post nurse staffing information every day.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Administration Deficiency — F0847
                  
                     Failure to: 
                     Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
                  
               
                     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
                  
                  
               
               Sep 5, 2024
               
               
            
            
                  1 deficiency 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
                  
                     Failure to: 
                     Develop and implement policies and procedures to prevent abuse, neglect, and theft.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Aug 20, 2024
               
               
            
            
                  3 deficiencies 
               
            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 — 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 — 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
                  
                  
               
               Jun 20, 2024
               
               
            
            
                  1 deficiency 
               
            Nursing and Physician Services Deficiency — F0729
                  
                     Failure to: 
                     Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Apr 4, 2024
               
               
            
            
                  2 deficiencies 
               
            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
                  
                  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 9, 2024
               
               
            
            
                  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
                  
                  
               
               Nov 28, 2023
               
               
            
            
                  1 deficiency 
               
            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
                  
                  
               
               Oct 27, 2023
               
               
            
            
                  17 deficiencies 
               
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Nutrition and Dietary Deficiency — F0804
                  
                     Failure to: 
                     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0684
                  
                     Failure to: 
                     Provide appropriate treatment and care according to orders, resident's preferences and goals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  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
                  
                  Infection Control Deficiency — F0880
                  
                     Failure to: 
                     Provide and implement an infection prevention and control program.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — 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 — 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
                  
                  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
                  
                  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
                  
                  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 — 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
                  
                  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 — 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
                  
                  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
                  
                  Resident Rights Deficiency — F0550
                  
                     Failure to: 
                     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident 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 — 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
                  
                  
               
               Oct 5, 2023
               
               
            
            
                  1 deficiency 
               
               
            Infection Control Deficiency — F0880
                  
                     Failure to: 
                     Provide and implement an infection prevention and control program.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Sep 21, 2023
               
               
            
            
                  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
                  
                  
               
               Aug 24, 2023
               
               
            
            
                  2 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Quality of Life and Care Deficiency — F0684
                  
                     Failure to: 
                     Provide appropriate treatment and care according to orders, resident's preferences and goals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0655
                  
                     Failure to: 
                     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Jul 20, 2023
               
               
            
            
                  1 deficiency 
               
            Resident Assessment and Care Planning Deficiency — F0656
                  
                     Failure to: 
                     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Jul 12, 2023
               
               
            
            
                  1 deficiency 
               
            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
                  
                  
               
               Apr 27, 2023
               
               
            
            
                  4 deficiencies 
               
            Resident Assessment and Care Planning Deficiency — F0636
                  
                     Failure to: 
                     Assess the resident completely in a timely manner  when first admitted, and then periodically, at least every 12 months.
                  
               
                     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 — F0677
                  
                     Failure to: 
                     Provide care and assistance to perform activities of daily living for any resident who is unable.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0684
                  
                     Failure to: 
                     Provide appropriate treatment and care according to orders, resident's preferences and goals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Feb 16, 2023
               
               
            
            
                  3 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Quality of Life and Care Deficiency — F0684
                  
                     Failure to: 
                     Provide appropriate treatment and care according to orders, resident's preferences and goals.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  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 — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Sep 2, 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
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Aug 25, 2022
               
               
            
            
                  1 deficiency 
               
            Administration Deficiency — F0867
                  
                     Failure to: 
                     Set up an ongoing quality assessment and assurance group to review quality deficiencies  and develop corrective plans of action.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Jul 28, 2022
               
               
            
            
                  1 deficiency 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
                  
                     Failure to: 
                     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  
               
               Apr 26, 2021
               
               
            
            
                  21 deficiencies 
               
               
            
               
                  
                  to
                  K
                  
               
            
            
            
         Pharmacy Service Deficiency — F0760
                  
                     Failure to: 
                     Ensure that residents are free from significant medication errors.
                  
               
                     Severity
                  
                  Immediate jeopardy to resident health or safety
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0755
                  
                     Failure to: 
                     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
                  
               
                     Severity
                  
                  Immediate jeopardy to resident health or safety
                  
                     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
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0688
                  
                     Failure to: 
                     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Infection Control Deficiency — F0880
                  
                     Failure to: 
                     Provide and implement an infection prevention and control program.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0656
                  
                     Failure to: 
                     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nursing and Physician Services Deficiency — F0725
                  
                     Failure to: 
                     Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0759
                  
                     Failure to: 
                     Ensure medication error rates are not 5 percent or greater.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0761
                  
                     Failure to: 
                     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0804
                  
                     Failure to: 
                     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0812
                  
                     Failure to: 
                     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  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
                  
                  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 — 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
                  
                  Quality of Life and Care Deficiency — F0790
                  
                     Failure to: 
                     Provide routine and 24-hour emergency dental care for 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 — 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 — 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 — 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
                  
                  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 — 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
                  
                  Nursing and Physician Services Deficiency — F0732
                  
                     Failure to: 
                     Post nurse staffing information every day.
                  
               
                     Severity
                  
                  No actual harm, with potential for minimal harm
                  
                     Scope
                  
                  Many 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.
   This home has no record of fines or payment suspensions for the past three years.