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🔎 Santa Clarita Post-acute Care Center

Inspection Results


Inspection Overview

Santa Clarita Post-acute Care Center has been cited for a total of 117 deficiencies since we began saving each survey.

In California, the average facility has **64.18 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2025-04-02
Correction Date: 2025-04-23
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: B

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Dispose of garbage and refuse properly.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that residents are free from significant medication errors.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: B

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2025-02-14
Correction Date: 2025-03-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2025-02-05
Correction Date: 2025-02-26
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2025-02-05
Correction Date: 2025-02-26
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2024-08-17
Correction Date: 2024-09-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2024-08-17
Correction Date: 2024-09-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2024-07-29
Correction Date: 2024-09-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Survey Date: 2024-07-29
Correction Date: 2024-09-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2024-07-29
Correction Date: 2024-09-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2024-07-29
Correction Date: 2024-09-01
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2024-07-02
Correction Date: 2024-08-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2024-07-02
Correction Date: 2024-08-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-06-04
Correction Date: 2024-06-24
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Give the resident's representative the ability to exercise the resident's rights.

Survey Date: 2024-03-13
Correction Date: 2024-03-25
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that residents are free from significant medication errors.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: J

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Keep all essential equipment working safely.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2024-02-09
Correction Date: 2024-03-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-02-01
Correction Date: 2024-02-16
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2023-09-25
Correction Date: 2023-10-09
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2023-09-25
Correction Date: 2023-10-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-09-25
Correction Date: 2023-10-09
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-02-03
Correction Date: 2023-03-30
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: J

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2023-02-03
Correction Date: 2023-03-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2023-02-03
Correction Date: 2023-03-30
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that residents are free from significant medication errors.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Make sure that a working call system is available in each resident's bathroom and bathing area.

Survey Date: 2023-02-03
Correction Date: 2023-02-27
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-11-04
Correction Date: 2022-11-14
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-08-17
Correction Date: 2022-09-02
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-01-10
Correction Date: 2022-01-18
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2021-10-12
Correction Date: 2021-10-22
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2021-09-13
Correction Date: 2021-09-13
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2020-09-18
Correction Date: 2020-10-05
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2020-07-18
Correction Date: 2020-07-22
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: B

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that residents are free from significant medication errors.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2019-08-06
Correction Date: 2019-09-05
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: B

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2019-08-06
Correction Date:
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2018-08-19
Correction Date: 2018-08-22
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2018-08-19
Correction Date: 2018-08-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2018-08-19
Correction Date: 2018-08-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2018-08-19
Correction Date: 2018-08-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2018-08-19
Correction Date: 2018-08-22
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2018-08-19
Correction Date: 2018-08-22
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2018-08-19
Correction Date: 2018-08-22
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2018-08-19
Correction Date: 2018-08-22
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2018-08-19
Correction Date: 2018-08-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: B

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Survey Date: 2018-08-19
Correction Date:
Category: Environmental Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**