Map showing the location of MIRAGE POST ACUTE in LANCASTER, California
44445 15TH ST W, LANCASTER, CA, 93534

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • CaliforniaLowest tier among peers1,154 rated homes · average 3.2★
  • Los Angeles CountyLowest tier among peers368 rated homes · average 2.5★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs CA avg
  • StaffingCan add or remove a star4★+0.9 vs CA avg
  • Quality measuresCan add or remove a star3★−1.1 vs CA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Special Focus Facility candidateThis facility is on the CMS candidate list for the Special Focus Facility program, meaning it is among the poorest-performing facilities in its state on recent inspections.
  • Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersCA avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 60% of peersCA avg3.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 9% of peersCA avg4.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff5.53hrsTop 9%CA avg4.51Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.42hrsAbove only 38% of peersCA avg0.65Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better48%Above only 21% of peersCA avg38%RN turnover40%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$117,614Above only 6% of peersCA avg$26,970Fines · denials2 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
255citations
62inspection dates
3actual harm (G–I)
3immediate jeopardy (J–L)
Dec 17, 2025most recent

Citations by monthJan 2023 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 17, 20251 citationCycle 1worst D · no actual harm
  1. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Dec 24, 2025
Nov 25, 20251 citationCycle 1worst D · no actual harm
  1. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Nov 26, 2025
Nov 24, 20254 citationsCycle 1worst G · actual harm
  1. F584Honor 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.Resident RightsD · isolatedCorrected Nov 25, 2025
  2. F880Provide and implement an infection prevention and control program.Infection ControlG · isolatedCorrected Nov 25, 2025
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Nov 25, 2025
  4. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Nov 25, 2025
Sep 5, 20255 citationsCycle 1worst E · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Sep 26, 2025
  2. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalD · isolatedCorrected Sep 26, 2025
  3. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected Sep 26, 2025
  4. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Sep 26, 2025
  5. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 26, 2025
Aug 21, 20257 citationsCycle 1worst G · actual harm
  1. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Sep 19, 2025
  2. F693Ensure 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.Quality of Life and CareD · isolatedCorrected Sep 19, 2025
  3. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Sep 26, 2025
  4. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Sep 19, 2025
  5. F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Sep 19, 2025
  6. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Sep 19, 2025
  7. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Sep 19, 2025
Aug 7, 20254 citationsCycle 1worst D · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Sep 3, 2025
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 3, 2025
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 3, 2025
  4. F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Sep 3, 2025
Jul 22, 20251 citationCycle 1worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 28, 2025
Jul 15, 20251 citationCycle 1worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Aug 8, 2025
Jul 9, 20254 citationsCycle 1worst E · no actual harm
  1. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jul 31, 2025
  2. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Jul 31, 2025
  3. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jul 31, 2025
  4. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Jul 31, 2025
Jun 5, 20252 citationsCycle 1worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jun 23, 2025
  2. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jun 23, 2025
May 16, 20254 citationsCycle 1worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jun 8, 2025
  2. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jun 8, 2025
  3. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jun 8, 2025
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jun 8, 2025
Apr 3, 20256 citationsCycle 1worst E · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Apr 27, 2025
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Apr 27, 2025
  3. F584Honor 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.Resident RightsD · isolatedCorrected Apr 27, 2025
  4. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 27, 2025
  5. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Apr 27, 2025
  6. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Apr 27, 2025
Mar 28, 20254 citationsCycle 1worst J · immediate jeopardy$99,263
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsJ · isolatedCorrected Apr 21, 2025
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareJ · isolatedCorrected Apr 21, 2025
  3. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Apr 21, 2025
  4. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Apr 21, 2025
Mar 12, 20252 citationsCycle 1worst E · no actual harm$99,263
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Apr 1, 2025
  2. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Apr 1, 2025
Mar 11, 20253 citationsCycle 1worst E · no actual harm$99,263
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Mar 13, 2025
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 13, 2025
  3. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Mar 13, 2025
Mar 10, 20252 citationsCycle 1worst D · no actual harm$99,263
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 30, 2025
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 30, 2025
Feb 25, 20252 citationsCycle 1worst D · no actual harm$18,351
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Feb 28, 2025
  2. F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Feb 28, 2025
Feb 7, 20251 citationCycle 1worst G · actual harm$18,351
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Feb 28, 2025
Feb 4, 20252 citationsCycle 1worst D · no actual harm$18,351
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Feb 5, 2025
  2. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Feb 5, 2025
Jan 28, 20253 citationsCycle 2worst D · no actual harm
  1. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Jan 30, 2025
  2. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Jan 30, 2025
  3. F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Jan 30, 2025
Jan 22, 20253 citationsCycle 2worst E · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Jan 25, 2025
  2. F732Post nurse staffing information every day.Nursing and Physician ServicesE · patternCorrected Jan 25, 2025
  3. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Jan 25, 2025
Jan 17, 202526 citationsCycle 1worst E · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Feb 5, 2025
  2. F584Honor 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.Resident RightsD · isolatedCorrected Feb 5, 2025
  3. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Feb 5, 2025
  4. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningB · patternCorrected Feb 5, 2025
  5. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Feb 5, 2025
  6. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Feb 5, 2025
  7. F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Feb 5, 2025
  8. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Feb 5, 2025
  9. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Feb 5, 2025
  10. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Feb 5, 2025
  11. F693Ensure 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.Quality of Life and CareD · isolatedCorrected Feb 5, 2025
  12. F700Try 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.Quality of Life and CareE · patternCorrected Feb 5, 2025
  13. F758Implement 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.Pharmacy ServiceE · patternCorrected Feb 5, 2025
  14. F761Ensure 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.Pharmacy ServiceE · patternCorrected Feb 5, 2025
  15. F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryE · patternCorrected Feb 5, 2025
  16. F803Ensure 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.Nutrition and DietaryE · patternCorrected Feb 5, 2025
  17. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Feb 5, 2025
  18. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryE · patternCorrected Feb 5, 2025
  19. F808Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Nutrition and DietaryE · patternCorrected Feb 5, 2025
  20. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Feb 5, 2025
  21. F814Dispose of garbage and refuse properly.Nutrition and DietaryE · patternCorrected Feb 5, 2025
  22. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Feb 5, 2025
  23. F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareE · patternCorrected Feb 5, 2025
  24. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Feb 5, 2025
  25. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Feb 5, 2025
  26. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsE · patternCorrected Feb 5, 2025
Jan 7, 20251 citationCycle 2worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jan 20, 2025
Jan 6, 20254 citationsCycle 2worst E · no actual harm
  1. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jan 24, 2025
  2. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jan 24, 2025
  3. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jan 24, 2025
  4. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jan 24, 2025
Dec 19, 20244 citationsCycle 2worst E · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jan 9, 2025
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jan 9, 2025
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Jan 9, 2025
  4. F584Honor 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.Resident RightsD · isolatedCorrected Jan 9, 2025
Dec 12, 20241 citationCycle 2worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 28, 2024
Dec 6, 20241 citationCycle 2worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 21, 2024
Nov 25, 20243 citationsCycle 2worst E · no actual harm
  1. F584Honor 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.Resident RightsD · isolatedCorrected Dec 16, 2024
  2. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Dec 16, 2024
  3. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Dec 16, 2024
Nov 15, 20243 citationsCycle 2worst D · no actual harm
  1. F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareD · isolatedCorrected Dec 12, 2024
  2. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Dec 12, 2024
  3. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Dec 12, 2024
Nov 14, 20241 citationCycle 2worst E · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Nov 30, 2024
Nov 13, 20245 citationsCycle 2worst D · no actual harm
  1. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Dec 2, 2024
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Dec 2, 2024
  3. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Dec 2, 2024
  4. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Dec 2, 2024
  5. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Dec 2, 2024
Oct 8, 20243 citationsCycle 2worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Oct 21, 2024
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Oct 21, 2024
  3. F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Oct 21, 2024
Oct 3, 20242 citationsCycle 2worst D · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Oct 22, 2024
  2. F693Ensure 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.Quality of Life and CareD · isolatedCorrected Oct 22, 2024
Sep 28, 202412 citationsCycle 2worst E · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Oct 18, 2024
  2. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Oct 18, 2024
  3. F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Oct 18, 2024
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Oct 18, 2024
  5. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Oct 18, 2024
  6. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Oct 18, 2024
  7. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Oct 18, 2024
  8. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Oct 18, 2024
  9. F693Ensure 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.Quality of Life and CareD · isolatedCorrected Oct 18, 2024
  10. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareE · patternCorrected Oct 18, 2024
  11. F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Oct 18, 2024
  12. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Oct 18, 2024
Sep 3, 20241 citationCycle 2worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 23, 2024
Aug 8, 20242 citationsCycle 2worst D · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Aug 20, 2024
  2. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Aug 20, 2024
Jul 11, 20241 citationCycle 2worst D · no actual harm
  1. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Jul 17, 2024
May 6, 20243 citationsCycle 2worst D · no actual harm
  1. F728Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.Nursing and Physician ServicesD · isolatedCorrected May 24, 2024
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected May 24, 2024
  3. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 24, 2024
May 1, 20242 citationsCycle 2worst D · no actual harm
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected May 10, 2024
  2. F758Implement 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.Pharmacy ServiceD · isolatedCorrected May 10, 2024
Apr 16, 20241 citationCycle 2worst D · no actual harm
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 25, 2024
Mar 18, 20249 citationsCycle 2worst E · no actual harm
  1. F688Provide 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.Quality of Life and CareD · isolatedCorrected Apr 4, 2024
  2. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Apr 4, 2024
  3. F675Honor each resident's preferences, choices, values and beliefs.Quality of Life and CareE · patternCorrected Apr 4, 2024
  4. F584Honor 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.Resident RightsD · isolatedCorrected Apr 4, 2024
  5. F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryD · isolatedCorrected Apr 4, 2024
  6. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Apr 4, 2024
  7. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 4, 2024
  8. F908Keep all essential equipment working safely.EnvironmentalE · patternCorrected Apr 4, 2024
  9. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Apr 4, 2024
Jan 26, 202441 citationsCycle 2worst E · no actual harm
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Feb 23, 2024
  2. Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Nutrition and DietaryD · isolatedCorrected Feb 23, 2024
  3. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Feb 23, 2024
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Feb 23, 2024
  5. Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Quality of Life and CareD · isolatedCorrected Feb 23, 2024
  6. Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningB · patternCorrected Feb 23, 2024
  7. 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.Resident RightsD · isolatedCorrected Feb 23, 2024
  8. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Feb 23, 2024
  9. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsE · patternCorrected Feb 23, 2024
  10. F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Resident RightsD · isolatedCorrected Feb 23, 2024
  11. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Feb 23, 2024
  12. F578Honor 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.Resident RightsE · patternCorrected Feb 23, 2024
  13. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Feb 23, 2024
  14. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Feb 23, 2024
  15. F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningB · patternCorrected Feb 23, 2024
  16. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningB · patternCorrected Feb 23, 2024
  17. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Feb 23, 2024
  18. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Feb 23, 2024
  19. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Feb 23, 2024
  20. F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected Feb 23, 2024
  21. F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Feb 23, 2024
  22. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Feb 23, 2024
  23. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Feb 23, 2024
  24. F693Ensure 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.Quality of Life and CareD · isolatedCorrected Feb 23, 2024
  25. F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareE · patternCorrected Feb 23, 2024
  26. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareE · patternCorrected Feb 23, 2024
  27. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Feb 23, 2024
  28. F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareE · patternCorrected Feb 23, 2024
  29. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Feb 23, 2024
  30. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceE · patternCorrected Feb 23, 2024
  31. F758Implement 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.Pharmacy ServiceE · patternCorrected Feb 23, 2024
  32. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Feb 23, 2024
  33. F761Ensure 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.Pharmacy ServiceE · patternCorrected Feb 23, 2024
  34. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Feb 23, 2024
  35. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Feb 23, 2024
  36. F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationE · patternCorrected Feb 23, 2024
  37. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Feb 23, 2024
  38. F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Feb 23, 2024
  39. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Feb 23, 2024
  40. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Feb 23, 2024
  41. F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected Feb 23, 2024
Jan 11, 20246 citationsCycle 3worst E · no actual harm
  1. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Feb 2, 2024
  2. F850Hire a qualified full-time social worker in a facility with more than 120 beds.AdministrationD · isolatedCorrected Feb 2, 2024
  3. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Feb 2, 2024
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Feb 2, 2024
  5. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareE · patternCorrected Feb 2, 2024
  6. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Feb 2, 2024
Nov 29, 20234 citationsCycle 3worst E · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 12, 2023
  2. F732Post nurse staffing information every day.Nursing and Physician ServicesD · isolatedCorrected Dec 12, 2023
  3. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Dec 12, 2023
  4. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Dec 12, 2023
Nov 7, 20235 citationsCycle 3worst E · no actual harm
  1. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Dec 2, 2023
  2. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Dec 2, 2023
  3. F803Ensure 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.Nutrition and DietaryE · patternCorrected Dec 2, 2023
  4. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Dec 2, 2023
  5. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Dec 2, 2023
Nov 1, 20233 citationsCycle 3worst E · no actual harm
  1. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Nov 16, 2023
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 16, 2023
  3. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Nov 16, 2023
Oct 29, 20233 citationsCycle 3worst D · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Nov 20, 2023
  2. F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.AdministrationD · isolatedCorrected Nov 20, 2023
  3. F885Report COVID19 data to residents and families.Infection ControlD · isolatedCorrected Nov 20, 2023
Oct 17, 20232 citationsCycle 3worst D · no actual harm
  1. F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Nov 2, 2023
  2. F584Honor 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.Resident RightsD · isolatedCorrected Nov 2, 2023
Oct 5, 20231 citationCycle 3worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Oct 17, 2023
Sep 13, 20232 citationsCycle 3worst E · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 13, 2023
  2. F732Post nurse staffing information every day.Nursing and Physician ServicesB · patternCorrected Oct 13, 2023
Jul 25, 20231 citationCycle 3worst D · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Aug 11, 2023
Jul 17, 20233 citationsCycle 3worst D · no actual harm
  1. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Aug 10, 2023
  2. F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Aug 10, 2023
  3. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Aug 10, 2023
Jul 14, 20231 citationCycle 3worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 4, 2023
Jul 5, 20233 citationsCycle 3worst E · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Jul 27, 2023
  2. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jul 27, 2023
  3. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jul 27, 2023
Jun 16, 20233 citationsCycle 3worst D · no actual harm
  1. F282Provide care by qualified persons according to each resident's written plan of care.Resident Assessment and Care PlanningD · isolatedCorrected Jul 7, 2023
  2. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesD · isolatedCorrected Jul 7, 2023
  3. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jul 7, 2023
Jun 14, 20231 citationCycle 3worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 23, 2023
Apr 17, 20231 citationCycle 3worst E · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected May 7, 2023
Apr 12, 20231 citationCycle 3worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Apr 25, 2023
Apr 11, 20231 citationCycle 3worst D · no actual harm
  1. F624Prepare residents for a safe transfer or discharge from the nursing home.Resident RightsD · isolatedCorrected May 3, 2023
Feb 21, 20232 citationsCycle 3worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 21, 2023
  2. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Mar 21, 2023
Feb 1, 20231 citationCycle 3worst D · no actual harm
  1. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected Feb 13, 2023
Jan 20, 202323 citationsCycle 3worst E · no actual harm
  1. F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Feb 20, 2023
  2. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Feb 20, 2023
  3. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Feb 20, 2023
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Feb 20, 2023
  5. F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Feb 20, 2023
  6. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Feb 20, 2023
  7. F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareD · isolatedCorrected Feb 20, 2023
  8. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Feb 20, 2023
  9. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Feb 20, 2023
  10. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Feb 20, 2023
  11. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Feb 20, 2023
  12. 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.Resident RightsD · isolatedCorrected Feb 20, 2023
  13. F761Ensure 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.Pharmacy ServiceE · patternCorrected Feb 20, 2023
  14. F881Implement a program that monitors antibiotic use.Infection ControlD · isolatedCorrected Feb 20, 2023
  15. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Feb 20, 2023
  16. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Feb 20, 2023
  17. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Feb 20, 2023
  18. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Feb 20, 2023
  19. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Feb 20, 2023
  20. F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected Feb 20, 2023
  21. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Feb 20, 2023
  22. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Feb 20, 2023
  23. F584Honor 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.Resident RightsD · isolatedCorrected Feb 20, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined5.53hrsTop 9%+1.02 vs CA avg
  • Registered nursesRN hours only0.42hrsAbove only 38% of peers−0.23 vs CA avg
  • Licensed practical nursesLPN hours1.48hrs
  • Nurse aidesCNA hours3.63hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.79hrs
  • California average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better48%Above only 21% of peersCA avg 38%
  • RN turnoverRegistered nurses only40%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy299 certified beds · ~253 residents a day85%Above only 22% of peersCA avg 88%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $117,614In fines
  • 2Fines
  • 0Payment denials
  • $26,970CA avg in fines
Above only 6% of peersFewer fines than 6% of rated homes in California

Actions on record

  1. Mar 10, 2025Civil money penalty$99,263
  2. Feb 7, 2025Civil money penalty$18,351

Ownership

As filed with CMS

Structure

Ownership type
For profit - Partnership
Chain
Pacs Group254 facilities in the chain2.9★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Providence Group Nh, LLC
Indirect owners (5%+)
  • Pacs Group, INC.
  • Pacs Holdings, LLC
  • Mark Hancock
  • Jason Murray
Operational or managerial control
  • Spencer Jack
Corporate officers
  • Frederick Apt
  • Mark Hancock
  • John Mitchell
  • Jason Murray
Managing employees
  • Spencer Jack

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 056039 · 44445 15TH ST W, LANCASTER, CA, 93534.
  • Percentiles compare this facility with every rated nursing home in California and Los Angeles County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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