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California CDPH state citations and administrative penalties, 1997 to early 2024 (archived dataset). Separate from federal CMS deficiencies.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D65 | E30 | F1 |
| Minimal | A· | B4 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Jul 16, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jun 9, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| May 12, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Apr 17, 2026 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Apr 17, 2026 | Health | Health Standard | 13 | Potential harm | — | Open → |
| Apr 3, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Mar 18, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 26, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 5, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Nov 26, 2025 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Oct 19, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Mar 28, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Mar 20, 2025 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Mar 20, 2025 | Health | Health Complaint, Health Standard | 13 | Potential harm | — | Open → |
| Mar 7, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 25, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jan 28, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Oct 3, 2024 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Sep 3, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 10, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Apr 17, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Apr 5, 2024 | Fire safety | Fire Safety Standard | 9 | Potential harm | — | Open → |
| Apr 5, 2024 | Health | Health Complaint, Health Standard | 22 | Potential harm | — | Open → |
| Feb 1, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 26, 2023 | Fire safety | Fire Safety Complaint | 1 | Minimal | — | Open → |
| Dec 26, 2023 | Health | Health Complaint | 6 | Potential harm | — | Open → |
| Dec 2, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Nov 15, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Oct 25, 2023 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Jan 8, 2024 | Civil money penalty (fine) | $4,938 | — | 555893|Fine|129717 |
| Jan 2, 2024 | Civil money penalty (fine) | $4,587 | — | 555893|Fine|129654 |
| Dec 11, 2023 | Civil money penalty (fine) | $13,635 | — | 555893|Fine|129485 |
| Issued | Class | Type | Category | Final amount | Flags | Record |
|---|---|---|---|---|---|---|
| Feb 15, 2024 violation Dec 25, 2023 | Class B | Citation Citation B (HSC 1424) | Refusal to Readmit | $3,150 initial $3,000 | Open | 950019743 |
| Feb 15, 2024 violation Dec 20, 2023 | Class B | Citation Citation B (HSC 1424) | Other · Abuse | $3,000 | Closed | 950019741 |
| Jan 17, 2024 violation Dec 2, 2023 | Class B | Citation Citation B (HSC 1424) | Other · Free from accident hazard | $3,000 | Closed |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D65 | E30 | F1 |
| Minimal | A· | B4 | C1 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jul 16, 2026 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 1, 2026 | Complaint |
| Jul 16, 2026 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 1, 2026 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Mayer Family 2016 Irrevocable Trust | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | Oct 1, 2020 |
| Ezequiel Bercovich | Individual | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | Dec 31, 2022 |
| Moises Bercovich | Individual | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | Oct 1, 2020 |
| Adam Zenou | Individual | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | Oct 1, 2020 |
| Ori Management LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 13% | Oct 10, 2023 |
| Jacob Unger | Individual | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Aug 20, 2020 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Mayer Family 2016 Irrevocable Trust | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | Oct 1, 2020 |
| Ezequiel Bercovich | Individual | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | Dec 31, 2022 |
| Moises Bercovich | Individual | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | Oct 1, 2020 |
| Adam Zenou | Individual | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | Oct 1, 2020 |
| Ori Management LLC | Organization |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Foothill Heights Care Center 1515 North Fair Oaks Ave, Pasadena, CA 91103 CCN 555894 | 0.1 km | 49 | Aug 21, 2026 | 80 | $9,390 | |
| Cedar Pine Post Acute 1640 N. Fair Oaks Avenue, Pasadena, CA 91103 CCN 5552133 state class AA/AAbuse icon | 0.2 km | 99 | Jun 26, 2026 | 1051 IJ1 harm | $9,113 | |
| Pasadena Grove Health Center 1470 N Fair Oaks Ave, Pasadena, CA 91103 CCN 055617 | 0.2 km | 71 | Aug 5, 2026 | 921 harm | — | |
| Saint Vincent Healthcare 1810 N. Fair Oaks Ave, Pasadena, CA 91103 CCN 555119 | 0.5 km | 78 | Nov 21, 2025 | 65 | — | |
| Brighton Care Center 1836 N. Fair Oaks Ave, Pasadena, CA 91103 CCN 555338 | 0.5 km | 99 | Aug 18, 2026 | 921 harm | — | |
| Golden Rose Care Center 1899 N Raymond Ave, Pasadena, CA 91103 CCN 0558629 state class AA/ASFF Candidate | 0.6 km | 99 | Aug 14, 2026 | 1613 IJ1 harm | $121k | |
| Camellia Gardens Care Center 1920 N. Fair Oaks Avenue, Pasadena, CA 91103 CCN 056316 | 0.7 km | 80 | Aug 27, 2026 | 73 | — | |
| Villa Gardens Health Care Unit 842 East Villa Street, Pasadena, CA 91101 CCN 555429 | 2.8 km | 54 | Dec 5, 2025 | 53 | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 555893 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 555893 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
| California CDPH Licensed Facility Listing CA | 970000186 | state_license, licensed_beds, licensee Linked to the CMS record by exact CCN. | Verified | Oct 16, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| 950019614 |
| May 11, 2023 violation Mar 21, 2023 | Class B | Citation Citation B (HSC 1424) | Abuse/Facility Not Self Reported | $3,000 | Closed | 950018744 |
| Dec 2, 2022 violation Sep 19, 2022 | Class B | Citation Citation B (HSC 1424) | Patient Care | $3,000 | Closed | 950018211 |
| Jul 29, 2022 violation Jan 21, 2022 | Class B | Citation Citation B (HSC 1424) | Patient Rights | $3,000 | Closed | 950017864 |
| Mar 2, 2022 violation Jan 13, 2022 | Class B | Citation Citation B (HSC 1424) | Patient Care | $2,000 | Closed | 950017456 |
| Jan 20, 2022 violation May 10, 2021 | Class B | Citation Citation B (HSC 1424) | Patient Care | $6,000 initial $2,000 | Closed | 950017275 |
| Dec 27, 2021 violation Sep 29, 2021 | Class B | Citation Citation B (HSC 1424) | Physical Environment | $3,550 initial $2,000 | Closed | 950017224 |
| Oct 29, 2021 violation Aug 23, 2021 | Class B | Citation Citation B (HSC 1424) | Patient Care | $6,000 initial $2,000 | Closed | 950017054 |
| Jul 16, 2021 violation Oct 1, 2019 | AP NHPPD | Administrative Penalty AP - 3.2 Nursing-Hours-per-Patient-Day AP (HSC 1276.5) | DHPPD: 1 Day (No Penalty) | $0 | Closed | 810016596 |
| Apr 14, 2021 violation Jan 14, 2021 | Class B | Citation Citation B (HSC 1424) | Patient Care | $2,000 | Closed | 950016418 |
| Mar 26, 2021 violation Jan 4, 2021 | Class B | Citation Citation B (HSC 1424) | Patient Care | $2,000 | Closed | 950016380 |
| Mar 12, 2021 violation Jan 14, 2021 | Class B | Citation Citation B (HSC 1424) | Staffing | $2,000 | Closed | 950016346 |
| Mar 12, 2021 violation Jan 14, 2021 | Class B | Citation Citation B (HSC 1424) | Patient Care | $6,000 initial $2,000 | Closed | 950016345 |
| Nov 25, 2020 violation Oct 16, 2020 | Class B | Citation Citation B (HSC 1424) | Patient Care | $2,000 | Closed | 950016169 |
| Dec 10, 2019 violation Jan 1, 2018 | AP NHPPD | Administrative Penalty AP - 3.2 Nursing-Hours-per-Patient-Day AP (HSC 1276.5) | DHPPD: 2 - 11 Days | $15,000 | Closed | 810015491 |
| Jun 21, 2019 violation Feb 1, 2019 | Class B | Citation Citation B (HSC 1424) | Abuse/Facility Not Self Reported | $2,000 | Closed | 950015178 |
| Sep 12, 2018 violation Dec 27, 2016 | AP NHPPD | Administrative Penalty AP - 3.2 Nursing-Hours-per-Patient-Day AP (HSC 1276.5) | DHPPD: 2 - 11 Days | $15,000 | Closed | 950014383 |
| Dec 1, 2017 violation May 25, 2017 | Class B | Citation Citation B (HSC 1424) | Other · Unusual Occurence | $2,000 | Closed | 950013667 |
| Dec 1, 2017 violation Aug 8, 2017 | Class B | Citation Citation B (HSC 1424) | Other · Infection Control | $2,000 | Closed | 950013666 |
| Mar 16, 2016 violation Mar 24, 2015 | Class A | Citation Citation A (HSC 1424) | Patient Care | $14,550 initial $14,000 | Closed | 950012052 |
| May 23, 2013 violation Jan 23, 2012 | AP NHPPD | Administrative Penalty AP - 3.2 Nursing-Hours-per-Patient-Day AP (HSC 1276.5) | DHPPD: 2 - 11 Days | $15,000 | Closed | 950009888 |
| Nov 1, 2011 violation Sep 16, 2011 | Class B | Citation Citation B (HSC 1424) | Other · Failed to post rating | $1,000 | Closed | 950008687 |
| Apr 14, 2008 violation Jul 26, 2007 | Class B | Citation Citation B (HSC 1424) | Patient Rights | $900 | Closed | 970004921 |
| Apr 18, 2007 violation Dec 2, 2006 | Class B | Citation Citation B (HSC 1424) | Patient Care | $1,000 | Closed | 970003905 |
| Jun 9, 2026 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 26, 2026 | Complaint |
| Jun 9, 2026 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 26, 2026 | Complaint |
| May 12, 2026 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 29, 2026 | Complaint |
| Apr 17, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 16, 2026 |
| Apr 17, 2026 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 16, 2026 |
| Apr 17, 2026 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 16, 2026 |
| Apr 17, 2026 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 16, 2026 |
| Apr 17, 2026 | F-0578 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 5, 2026 |
| Apr 17, 2026 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 8, 2026 |
| Apr 17, 2026 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 5, 2026 |
| Apr 17, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 18, 2026 |
| Apr 17, 2026 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 8, 2026 |
| Apr 17, 2026 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 8, 2026 |
| Apr 17, 2026 | F-0803 | 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. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Apr 18, 2026 |
| Apr 17, 2026 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Apr 18, 2026 |
| Apr 17, 2026 | F-0849 | 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. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected May 8, 2026 |
| Apr 17, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected May 8, 2026 |
| Apr 17, 2026 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 18, 2026 |
| Apr 17, 2026 | F-0887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 18, 2026 |
| Apr 17, 2026 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 18, 2026 |
| Apr 3, 2026 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 10, 2026 | Complaint |
| Mar 18, 2026 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 6, 2026 | Complaint |
| Feb 26, 2026 | F-0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 13, 2026 | Complaint |
| Feb 5, 2026 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 9, 2026 | Complaint |
| Feb 5, 2026 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 9, 2026 | Complaint |
| Nov 26, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Dec 19, 2025 | Complaint |
| Nov 26, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Dec 19, 2025 | Complaint |
| Nov 26, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Dec 19, 2025 | Complaint |
| Oct 19, 2025 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 20, 2025 | Complaint |
| Mar 28, 2025 | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 14, 2025 | Complaint |
| Mar 28, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 14, 2025 | Complaint |
| Mar 20, 2025 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 10, 2025 |
| Mar 20, 2025 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 10, 2025 |
| Mar 20, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 10, 2025 |
| Mar 20, 2025 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Apr 10, 2025 |
| Mar 20, 2025 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 20, 2025 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 20, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 20, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Mar 20, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 11, 2025 | Complaint |
| Mar 20, 2025 | F-0693 | 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. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 20, 2025 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 20, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 20, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 20, 2025 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 14, 2025 |
| Mar 20, 2025 | F-0926 | Have policies on smoking. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 14, 2025 |
| Mar 20, 2025 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | B · Minimal Pattern | Corrected Apr 14, 2025 |
| Mar 20, 2025 | F-0912 | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Environmental Deficiencies · Environment & life safety | B · Minimal Pattern | Corrected Apr 14, 2025 |
| Mar 7, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 31, 2025 | Complaint |
| Feb 25, 2025 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 21, 2025 | Complaint |
| Feb 25, 2025 | F-0758 | 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. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Mar 21, 2025 | Complaint |
| Jan 28, 2025 | F-0626 | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 10, 2025 | Complaint |
| Oct 3, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Oct 25, 2024 | Complaint |
| Sep 3, 2024 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 21, 2024 | Complaint |
| May 10, 2024 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 10, 2024 | Complaint |
| Apr 17, 2024 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 17, 2024 | Complaint |
| Apr 17, 2024 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 17, 2024 | Complaint |
| Apr 5, 2024 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 7, 2024 |
| Apr 5, 2024 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 7, 2024 |
| Apr 5, 2024 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 7, 2024 |
| Apr 5, 2024 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0578 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0656 | Develop 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 Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0657 | Develop 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 Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0693 | 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. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 7, 2024 | Complaint |
| Apr 5, 2024 | F-0700 | 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. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | B · Minimal Pattern | Corrected May 7, 2024 |
| Apr 5, 2024 | F-0912 | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Environmental Deficiencies · Environment & life safety | B · Minimal Pattern | Corrected May 7, 2024 |
| Feb 1, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 1, 2024 | Complaint |
| Dec 26, 2023 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 25, 2024 | Complaint |
| Dec 26, 2023 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 25, 2024 | Complaint |
| Dec 26, 2023 | F-0626 | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 25, 2024 | Complaint |
| Dec 26, 2023 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 25, 2024 | Complaint |
| Dec 26, 2023 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jan 25, 2024 | Complaint |
| Dec 26, 2023 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 25, 2024 | Complaint |
| Dec 26, 2023 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | C · Minimal Widespread | Corrected Jan 24, 2024 | Complaint |
| Dec 2, 2023 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jan 1, 2024 | Complaint |
| Nov 15, 2023 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 15, 2023 | Complaint |
| Oct 25, 2023 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 14, 2023 | Complaint |
| Oct 25, 2023 | F-0656 | Develop 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 Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 14, 2023 | Complaint |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 5.62 (case-mix index 1.17).
| Direct owner |
| 5% OR GREATER DIRECT OWNERSHIP INTEREST |
| 13% |
| Oct 10, 2023 |
| Jacob Unger | Individual | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Aug 20, 2020 |
| Shahrzad Jannat | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 13, 2024 |
| Shahrzad Jannat | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 13, 2024 |
| Arlene Rosales | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Dec 28, 2017 |