Mirage Post Acute

44445 15th St W, Lancaster, CA 93534

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Mirage Post Acute is a nursing home in Lancaster, California. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.

This page uses data from the Centers for Medicare & Medicaid Services (CMS), published on October 28, 2026. CMS updates its data about once a month.

Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.

CMS star ratings

1 of 5CMS overall star rating
1 of 5CMS health inspection star rating
2 of 5CMS staffing star rating
4 of 5CMS quality measures star rating

Facts from CMS

Phone: (661) 948-7501
Last standard health inspection: April 24, 2026 (6 months ago)
Certified beds: 299
Residents per day, on average: 273.1
Ownership type: For profit - Partnership
Legal business name: Lancaster SNF Healthcare LLC
Chain: Pacs Group
Takes part in: Medicare and Medicaid

More health citations than the California average (276 vs 50).

Inspections, fines and changes

This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.

CMS update of October 28, 2026
- Star rating
  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
1 citation
Health inspection on August 25, 2026
CMS lists this as a complaint inspection.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on September 15, 2026.
  CMS has cited this home for F0842 20 times since 2023.
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1 citation
Health inspection on August 21, 2026
CMS lists this as a complaint inspection.
- Citation F0695. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.
  CMS has cited this home for F0695 5 times since 2025.
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1 citation
Health inspection on August 10, 2026
CMS lists this as a complaint inspection.
- Citation F0921. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  CMS lists it as corrected on August 18, 2026.
  CMS has cited this home for F0921 4 times since 2025.
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CMS update of July 29, 2026
- Star rating
  The CMS staffing star rating changed from 3 of 5 to 2 of 5.
7 citations
Health inspection on July 1, 2026
CMS lists this as a complaint inspection.
- Citation F0755. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on July 16, 2026.
  CMS has cited this home for F0755 16 times since 2023.
- Citation F0842. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on July 16, 2026.
- Citation F0580. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  CMS lists it as corrected on July 16, 2026.
  CMS has cited this home for F0580 8 times since 2023.
- Citation F0641. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure each resident receives an accurate assessment.
  CMS lists it as corrected on July 16, 2026.
  CMS has cited this home for F0641 2 times since 2024.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on July 16, 2026.
  CMS has cited this home for F0656 15 times since 2023.
- Citation F0684. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  CMS lists it as corrected on July 16, 2026.
  CMS has cited this home for F0684 11 times since 2024.
- Citation F0686. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  CMS lists it as corrected on July 16, 2026.
  CMS has cited this home for F0686 11 times since 2024.
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2 citations
Health inspection on June 17, 2026
CMS lists this as a complaint inspection.
- Citation F0550. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  CMS lists it as corrected on July 8, 2026.
  CMS has cited this home for F0550 9 times since 2024.
- Citation F0849. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on July 8, 2026.
  CMS has cited this home for F0849 2 times since 2024.
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2 citations
Health inspection on June 13, 2026
CMS lists this as a complaint inspection.
- Citation F0584. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on July 2, 2026.
  CMS has cited this home for F0584 9 times since 2023.
- Citation F0880. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on July 2, 2026.
  CMS has cited this home for F0880 15 times since 2023.
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9 citations
Health inspection on June 9, 2026
CMS lists this as a complaint inspection.
- Citation F0755. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on June 23, 2026.
- Citation F0550. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  CMS lists it as corrected on June 23, 2026.
- Citation F0580. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  CMS lists it as corrected on June 23, 2026.
- Citation F0628. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  CMS lists it as corrected on June 23, 2026.
- Citation F0686. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  CMS lists it as corrected on June 23, 2026.
- Citation F0757. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.
  CMS lists it as corrected on June 23, 2026.
  CMS has cited this home for F0757 3 times since 2024.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on June 23, 2026.
- Citation F0880. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on June 23, 2026.
- Citation F0881. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Implement a program that monitors antibiotic use.
  CMS lists it as corrected on June 23, 2026.
  CMS has cited this home for F0881 2 times since 2026.
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1 citation
Health inspection on June 2, 2026
CMS lists this as a complaint inspection.
- Citation F0627. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
  CMS lists it as corrected on June 18, 2026.
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1 citation
Health inspection on May 29, 2026
CMS lists this as a complaint inspection.
- Citation F0551. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Give the resident's representative the ability to exercise the resident's rights.
  CMS lists it as corrected on June 12, 2026.
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3 citations
Health inspection on May 22, 2026
CMS lists this as a complaint inspection.
- Citation F0550. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  CMS lists it as corrected on June 5, 2026.
- Citation F0580. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  CMS lists it as corrected on June 5, 2026.
- Citation F0697. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.
  CMS lists it as corrected on June 5, 2026.
  CMS has cited this home for F0697 5 times since 2024.
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CMS update of April 29, 2026
- Star rating
  The CMS staffing star rating changed from 4 of 5 to 3 of 5.
- CMS abuse icon
  CMS removed its abuse icon from this home.
- Staffing
  Total nurse staffing reported to CMS went from 5.5 to 4.8 hours per resident per day.
2 citations
Health inspection on April 28, 2026
CMS lists this as a complaint inspection.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on May 11, 2026.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on May 11, 2026.
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23 citations
Health inspection on April 24, 2026
CMS lists this as a standard inspection.
- Citation F0578. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0578 2 times since 2024.
- Citation F0604. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0604 3 times since 2024.
- Citation F0656. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on May 15, 2026.
- Citation F0689. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0689 12 times since 2023.
- Citation F0690. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0690 4 times since 2024.
- Citation F0695. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.
  CMS lists it as corrected on May 15, 2026.
- Citation F0700. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0700 2 times since 2025.
- Citation F0760. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that residents are free from significant medication errors.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0760 7 times since 2023.
- Citation F0803. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0803 3 times since 2023.
- Citation F0812. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0812 3 times since 2024.
- Citation F0881. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Implement a program that monitors antibiotic use.
  CMS lists it as corrected on May 15, 2026.
- Citation F0908. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Keep all essential equipment working safely.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0908 3 times since 2024.
- Citation F0550. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  CMS lists it as corrected on May 15, 2026.
- Citation F0584. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on May 15, 2026.
- Citation F0605. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0605 2 times since 2026.
- Citation F0609. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0609 6 times since 2023.
- Citation F0657. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0657 4 times since 2024.
- Citation F0658. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0658 3 times since 2024.
- Citation F0685. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Assist a resident in gaining access to vision and hearing services.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0685 2 times since 2024.
- Citation F0688. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0688 2 times since 2024.
- Citation F0692. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.
  CMS lists it as corrected on May 15, 2026.
  CMS has cited this home for F0692 2 times since 2023.
- Citation F0790. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide routine and 24-hour emergency dental care for each resident.
  CMS lists it as corrected on May 15, 2026.
- Citation F0880. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on May 15, 2026.
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6 citations
Fire safety inspection on April 24, 2026
CMS lists this as a standard inspection.
- Citation K0345. Severity F: potential for more than minimal harm, widespread.
  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.
  CMS lists it as corrected on April 30, 2026.
- Citation K0353. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.
  CMS lists it as corrected on April 30, 2026.
  CMS has cited this home for K0353 3 times since 2024.
- Citation K0712. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Have simulated fire drills held at unexpected times.
  CMS lists it as corrected on April 30, 2026.
  CMS has cited this home for K0712 2 times since 2024.
- Citation K0761. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.
  CMS lists it as corrected on April 30, 2026.
  CMS has cited this home for K0761 2 times since 2025.
- Citation K0511. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Have properly installed electrical wiring and gas equipment.
  CMS lists it as corrected on April 30, 2026.
  CMS has cited this home for K0511 3 times since 2024.
- Citation K0920. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure proper usage of power strips and extension cords.
  CMS lists it as corrected on April 30, 2026.
  CMS has cited this home for K0920 2 times since 2024.
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1 citation
Health inspection on March 6, 2026
CMS lists this as a complaint inspection.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on March 16, 2026.
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CMS update of February 25, 2026
- Star rating
  The CMS quality measures star rating changed from 1 of 5 to 3 of 5.
- Fine
  CMS changed the fine from February 7, 2025 from $17,940 to $18,351.
- Fine
  CMS changed the fine from March 10, 2025 from $97,039 to $99,263.
1 citation
Health inspection on February 2, 2026
CMS lists this as a complaint inspection.
- Citation F0921. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  CMS lists it as corrected on February 4, 2026.
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7 citations
Health inspection on January 30, 2026
CMS lists this as a complaint inspection.
- Citation F0605. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  CMS lists it as corrected on March 2, 2026.
- Citation F0697. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.
  CMS lists it as corrected on March 2, 2026.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on March 2, 2026.
- Citation F0689. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  CMS lists it as corrected on March 2, 2026.
- Citation F0695. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.
  CMS lists it as corrected on March 2, 2026.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on March 2, 2026.
- Citation F0880. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on March 2, 2026.
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2 citations
Health inspection on January 20, 2026
CMS lists this as a complaint inspection.
- Citation F0925. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  CMS lists it as corrected on February 19, 2026.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on February 19, 2026.
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1 citation
Health inspection on December 17, 2025
CMS lists this as a complaint inspection.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on December 24, 2025.
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1 citation
Health inspection on November 25, 2025
CMS lists this as a complaint inspection.
- Citation F0657. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  CMS lists it as corrected on November 26, 2025.
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4 citations
Health inspection on November 24, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
227 of 1,165 California homes (19%) got a citation at the actual harm level in 2025.
- Citation F0880. Severity G: actual harm, isolated.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on November 25, 2025.
- Citation F0689. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  CMS lists it as corrected on November 25, 2025.
- Citation F0584. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on November 25, 2025.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on November 25, 2025.
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CMS update of November 20, 2025
- Star rating
  The CMS staffing star rating changed from 2 of 5 to 4 of 5.
- Fine
  CMS changed the fine from January 20, 2023 from $19,500 to $9,750.
- Fine
  CMS changed the fine from February 7, 2025 from $27,600 to $17,940.
- Fine
  CMS changed the fine from March 10, 2025 from $149,290 to $97,039.
5 citations
Health inspection on September 5, 2025
CMS lists this as a complaint inspection.
- Citation F0550. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  CMS lists it as corrected on September 26, 2025.
- Citation F0689. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  CMS lists it as corrected on September 26, 2025.
- Citation F0755. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on September 26, 2025.
- Citation F0919. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Make sure that a working call system is available in each resident's bathroom and bathing area.
  CMS lists it as corrected on September 26, 2025.
- Citation F0921. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  CMS lists it as corrected on September 26, 2025.
See this home on CMS Care Compare
7 citations
Health inspection on August 21, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
227 of 1,165 California homes (19%) got a citation at the actual harm level in 2025.
- Citation F0689. Severity G: actual harm, isolated.
  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  CMS lists it as corrected on September 19, 2025.
- Citation F0585. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Honor 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.
  CMS lists it as corrected on September 19, 2025.
  CMS has cited this home for F0585 4 times since 2023.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on September 19, 2025.
- Citation F0657. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  CMS lists it as corrected on September 19, 2025.
- Citation F0693. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on September 19, 2025.
  CMS has cited this home for F0693 5 times since 2024.
- Citation F0755. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on September 19, 2025.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on September 26, 2025.
See this home on CMS Care Compare
4 citations
Health inspection on August 7, 2025
CMS lists this as a complaint inspection.
- Citation F0609. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  CMS lists it as corrected on September 3, 2025.
- Citation F0679. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide activities to meet all resident's needs.
  CMS lists it as corrected on September 3, 2025.
  CMS has cited this home for F0679 3 times since 2024.
- Citation F0684. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  CMS lists it as corrected on September 3, 2025.
- Citation F0880. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on September 3, 2025.
See this home on CMS Care Compare
1 citation
Health inspection on July 22, 2025
CMS lists this as a complaint inspection.
- Citation F0689. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  CMS lists it as corrected on August 28, 2025.
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Fine
July 22, 2025 (1 year ago)
CMS fine of $36,377 on July 22, 2025.
See this home on CMS Care Compare
1 citation
Health inspection on July 15, 2025
CMS lists this as a complaint inspection.
- Citation F0755. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on August 8, 2025.
See this home on CMS Care Compare
4 citations
Health inspection on July 9, 2025
CMS lists this as a complaint inspection.
- Citation F0695. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.
  CMS lists it as corrected on July 31, 2025.
- Citation F0842. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on July 31, 2025.
- Citation F0558. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.
  CMS lists it as corrected on July 31, 2025.
  CMS has cited this home for F0558 6 times since 2024.
- Citation F0697. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.
  CMS lists it as corrected on July 31, 2025.
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CMS update of June 25, 2025
- Health citation
  CMS removed citation F0758 from the health inspection on January 17, 2025.
2 citations
Health inspection on June 5, 2025
CMS lists this as a complaint inspection.
- Citation F0558. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.
  CMS lists it as corrected on June 23, 2025.
- Citation F0684. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  CMS lists it as corrected on June 23, 2025.
See this home on CMS Care Compare
4 citations
Health inspection on May 16, 2025
CMS lists this as a complaint inspection.
- Citation F0684. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  CMS lists it as corrected on June 8, 2025.
- Citation F0686. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  CMS lists it as corrected on June 8, 2025.
- Citation F0697. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.
  CMS lists it as corrected on June 8, 2025.
- Citation F0755. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on June 8, 2025.
See this home on CMS Care Compare
6 citations
Health inspection on April 3, 2025
CMS lists this as a complaint inspection.
- Citation F0755. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on April 27, 2025.
- Citation F0584. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on April 27, 2025.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on April 27, 2025.
- Citation F0677. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.
  CMS lists it as corrected on April 27, 2025.
  CMS has cited this home for F0677 4 times since 2023.
- Citation F0684. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  CMS lists it as corrected on April 27, 2025.
- Citation F0686. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  CMS lists it as corrected on April 27, 2025.
See this home on CMS Care Compare
4 citations
Health inspection on March 28, 2025
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
86 of 1,165 California homes (7%) got a citation at the immediate jeopardy level in 2025.
- Citation F0580. Severity J: immediate jeopardy, isolated.
  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  CMS lists it as corrected on April 21, 2025.
- Citation F0600. Severity J: immediate jeopardy, isolated.
  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  CMS lists it as corrected on April 21, 2025.
  CMS has cited this home for F0600 7 times since 2023.
- Citation F0684. Severity J: immediate jeopardy, isolated.
  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  CMS lists it as corrected on April 21, 2025.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on April 21, 2025.
See this home on CMS Care Compare
2 citations
Health inspection on March 12, 2025
CMS lists this as a complaint inspection.
- Citation F0760. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that residents are free from significant medication errors.
  CMS lists it as corrected on April 1, 2025.
- Citation F0558. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.
  CMS lists it as corrected on April 1, 2025.
See this home on CMS Care Compare
3 citations
Health inspection on March 11, 2025
CMS lists this as a complaint inspection.
- Citation F0656. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on March 13, 2025.
- Citation F0684. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  CMS lists it as corrected on March 13, 2025.
- Citation F0686. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  CMS lists it as corrected on March 13, 2025.
See this home on CMS Care Compare
2 citations
Health inspection on March 10, 2025
CMS lists this as a complaint inspection.
- Citation F0600. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  CMS lists it as corrected on March 30, 2025.
- Citation F0609. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  CMS lists it as corrected on March 30, 2025.
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Fine
March 10, 2025 (1 year ago)
CMS fine of $99,263 on March 10, 2025.
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CMS update of February 26, 2025
- Star rating
  The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
- Star rating
  The CMS staffing star rating changed from 1 of 5 to 2 of 5.
- Star rating
  The CMS quality measures star rating changed from 5 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
- CMS abuse icon
  CMS added its abuse icon to this home.
2 citations
Health inspection on February 25, 2025
CMS lists this as a complaint inspection.
- Citation F0600. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  CMS lists it as corrected on February 28, 2025.
- Citation F0676. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
  CMS lists it as corrected on February 28, 2025.
  CMS has cited this home for F0676 2 times since 2025.
See this home on CMS Care Compare
1 citation
Health inspection on February 7, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
227 of 1,165 California homes (19%) got a citation at the actual harm level in 2025.
- Citation F0600. Severity G: actual harm, isolated.
  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  CMS lists it as corrected on February 28, 2025.
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Fine
February 7, 2025 (1 year ago)
CMS fine of $18,351 on February 7, 2025.
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2 citations
Health inspection on February 4, 2025
CMS lists this as a complaint inspection.
- Citation F0583. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Keep residents' personal and medical records private and confidential.
  CMS lists it as corrected on February 5, 2025.
- Citation F0755. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on February 5, 2025.
See this home on CMS Care Compare
3 citations
Health inspection on January 28, 2025
CMS lists this as a complaint inspection.
- Citation F0585. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Honor 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.
  CMS lists it as corrected on January 30, 2025.
- Citation F0690. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  CMS lists it as corrected on January 30, 2025.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on January 30, 2025.
See this home on CMS Care Compare
3 citations
Health inspection on January 22, 2025
CMS lists this as a complaint inspection.
- Citation F0732. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Post nurse staffing information every day.
  CMS lists it as corrected on January 25, 2025.
  CMS has cited this home for F0732 2 times since 2023.
- Citation F0760. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that residents are free from significant medication errors.
  CMS lists it as corrected on January 25, 2025.
- Citation F0921. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  CMS lists it as corrected on January 25, 2025.
See this home on CMS Care Compare
26 citations
Health inspection on January 17, 2025
CMS lists this as a standard inspection and a complaint inspection.
- Citation F0558. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.
  CMS lists it as corrected on February 5, 2025.
- Citation F0604. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  CMS lists it as corrected on February 5, 2025.
- Citation F0656. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on February 5, 2025.
- Citation F0658. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.
  CMS lists it as corrected on February 5, 2025.
- Citation F0694. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide for the safe, appropriate administration of IV fluids for a resident when needed.
  CMS lists it as corrected on February 5, 2025.
  CMS has cited this home for F0694 3 times since 2024.
- Citation F0700. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 5, 2025.
- Citation F0755. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on February 5, 2025.
- Citation F0758. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 5, 2025.
  CMS has cited this home for F0758 3 times since 2024.
- Citation F0760. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that residents are free from significant medication errors.
  CMS lists it as corrected on February 5, 2025.
- Citation F0761. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 5, 2025.
  CMS has cited this home for F0761 2 times since 2024.
- Citation F0802. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
  CMS lists it as corrected on February 5, 2025.
- Citation F0803. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 5, 2025.
- Citation F0804. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  CMS lists it as corrected on February 5, 2025.
  CMS has cited this home for F0804 2 times since 2023.
- Citation F0805. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  CMS lists it as corrected on February 5, 2025.
- Citation F0808. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure 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.
  CMS lists it as corrected on February 5, 2025.
- Citation F0812. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  CMS lists it as corrected on February 5, 2025.
- Citation F0814. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Dispose of garbage and refuse properly.
  CMS lists it as corrected on February 5, 2025.
- Citation F0880. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on February 5, 2025.
- Citation F0554. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.
  CMS lists it as corrected on February 5, 2025.
- Citation F0584. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 5, 2025.
- Citation F0676. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
  CMS lists it as corrected on February 5, 2025.
- Citation F0686. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  CMS lists it as corrected on February 5, 2025.
- Citation F0689. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  CMS lists it as corrected on February 5, 2025.
- Citation F0690. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  CMS lists it as corrected on February 5, 2025.
- Citation F0693. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 5, 2025.
- Citation F0645. Severity B: potential for minimal harm, pattern.
  The rule CMS cited: PASARR screening for Mental disorders or Intellectual Disabilities
  CMS lists it as corrected on February 5, 2025.
See this home on CMS Care Compare
7 citations
Fire safety inspection on January 17, 2025
CMS lists this as a standard inspection.
- Citation K0353. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.
  CMS lists it as corrected on February 5, 2025.
- Citation K0511. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Have properly installed electrical wiring and gas equipment.
  CMS lists it as corrected on February 5, 2025.
- Citation K0761. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.
  CMS lists it as corrected on February 5, 2025.
- Citation K0342. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
  CMS lists it as corrected on February 5, 2025.
- Citation K0351. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Install an approved automatic sprinkler system.
  CMS lists it as corrected on February 5, 2025.
  CMS has cited this home for K0351 2 times since 2024.
- Citation K0363. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Install corridor and hallway doors that block smoke.
  CMS lists it as corrected on February 5, 2025.
  CMS has cited this home for K0363 2 times since 2024.
- Citation K0923. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Have proper medical gas storage and administration areas.
  CMS lists it as corrected on February 5, 2025.
  CMS has cited this home for K0923 2 times since 2024.
See this home on CMS Care Compare
1 citation
Health inspection on January 7, 2025
CMS lists this as a complaint inspection.
- Citation F0755. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on January 20, 2025.
See this home on CMS Care Compare
4 citations
Health inspection on January 6, 2025
CMS lists this as a complaint inspection.
- Citation F0880. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on January 24, 2025.
- Citation F0686. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  CMS lists it as corrected on January 24, 2025.
- Citation F0695. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.
  CMS lists it as corrected on January 24, 2025.
- Citation F0755. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on January 24, 2025.
See this home on CMS Care Compare
CMS update of December 20, 2024
- Special Focus Facility
  CMS now lists this home as a Special Focus Facility candidate.
4 citations
Health inspection on December 19, 2024
CMS lists this as a complaint inspection.
- Citation F0689. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  CMS lists it as corrected on January 9, 2025.
- Citation F0550. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  CMS lists it as corrected on January 9, 2025.
- Citation F0584. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on January 9, 2025.
- Citation F0600. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  CMS lists it as corrected on January 9, 2025.
See this home on CMS Care Compare
1 citation
Health inspection on December 12, 2024
CMS lists this as a complaint inspection.
- Citation F0609. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  CMS lists it as corrected on December 28, 2024.
See this home on CMS Care Compare
1 citation
Health inspection on December 6, 2024
CMS lists this as a complaint inspection.
- Citation F0609. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  CMS lists it as corrected on December 21, 2024.
See this home on CMS Care Compare
3 citations
Health inspection on November 25, 2024
CMS lists this as a complaint inspection.
- Citation F0842. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on December 16, 2024.
- Citation F0584. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on December 16, 2024.
- Citation F0880. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on December 16, 2024.
See this home on CMS Care Compare
3 citations
Health inspection on November 15, 2024
CMS lists this as a complaint inspection.
- Citation F0580. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  CMS lists it as corrected on December 12, 2024.
- Citation F0694. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide for the safe, appropriate administration of IV fluids for a resident when needed.
  CMS lists it as corrected on December 12, 2024.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on December 12, 2024.
See this home on CMS Care Compare
1 citation
Health inspection on November 14, 2024
CMS lists this as a complaint inspection.
- Citation F0880. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on November 30, 2024.
See this home on CMS Care Compare
5 citations
Health inspection on November 13, 2024
CMS lists this as a complaint inspection.
- Citation F0580. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  CMS lists it as corrected on December 2, 2024.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on December 2, 2024.
- Citation F0677. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.
  CMS lists it as corrected on December 2, 2024.
- Citation F0689. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  CMS lists it as corrected on December 2, 2024.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on December 2, 2024.
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CMS update of October 30, 2024
- Name
  CMS lists a new legal business name for this home.
- Ownership
  CMS lists this home under a new chain.
- Ownership
  CMS ownership records list new owners for this home.
3 citations
Health inspection on October 8, 2024
CMS lists this as a complaint inspection.
- Citation F0677. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.
  CMS lists it as corrected on October 21, 2024.
- Citation F0679. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide activities to meet all resident's needs.
  CMS lists it as corrected on October 21, 2024.
- Citation F0755. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on October 21, 2024.
See this home on CMS Care Compare
2 citations
Health inspection on October 3, 2024
CMS lists this as a complaint inspection.
- Citation F0580. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  CMS lists it as corrected on October 22, 2024.
- Citation F0693. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on October 22, 2024.
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12 citations
Health inspection on September 28, 2024
CMS lists this as a complaint inspection.
- Citation F0686. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  CMS lists it as corrected on October 18, 2024.
- Citation F0755. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on October 18, 2024.
- Citation F0842. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on October 18, 2024.
- Citation F0550. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  CMS lists it as corrected on October 18, 2024.
- Citation F0558. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.
  CMS lists it as corrected on October 18, 2024.
- Citation F0585. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Honor 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.
  CMS lists it as corrected on October 18, 2024.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on October 18, 2024.
- Citation F0679. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide activities to meet all resident's needs.
  CMS lists it as corrected on October 18, 2024.
- Citation F0684. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  CMS lists it as corrected on October 18, 2024.
- Citation F0693. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on October 18, 2024.
- Citation F0757. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.
  CMS lists it as corrected on October 18, 2024.
- Citation F0880. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on October 18, 2024.
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1 citation
Health inspection on September 3, 2024
CMS lists this as a complaint inspection.
- Citation F0689. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  CMS lists it as corrected on September 23, 2024.
See this home on CMS Care Compare
2 citations
Health inspection on August 8, 2024
CMS lists this as a complaint inspection.
- Citation F0552. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.
  CMS lists it as corrected on August 20, 2024.
  CMS has cited this home for F0552 2 times since 2024.
- Citation F0760. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that residents are free from significant medication errors.
  CMS lists it as corrected on August 20, 2024.
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CMS update of July 31, 2024
- Star rating
  The CMS staffing star rating changed from 3 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
- Name
  CMS lists a new name for this home. It was WELLSPRINGS POST ACUTE CENTER.
1 citation
Health inspection on July 11, 2024
CMS lists this as a complaint inspection.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on July 17, 2024.
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3 citations
Health inspection on May 6, 2024
CMS lists this as a complaint inspection.
- Citation F0550. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  CMS lists it as corrected on May 24, 2024.
- Citation F0607. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  CMS lists it as corrected on May 24, 2024.
- Citation F0728. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure 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.
  CMS lists it as corrected on May 24, 2024.
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2 citations
Health inspection on May 1, 2024
CMS lists this as a complaint inspection.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on May 10, 2024.
- Citation F0758. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on May 10, 2024.
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CMS update of April 25, 2024
- Star rating
  The CMS overall star rating changed from 1 of 5 to 2 of 5.
- Star rating
  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
1 citation
Health inspection on April 16, 2024
CMS lists this as a complaint inspection.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on April 25, 2024.
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9 citations
Health inspection on March 18, 2024
CMS lists this as a complaint inspection.
- Citation F0675. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Honor each resident's preferences, choices, values and beliefs.
  CMS lists it as corrected on April 4, 2024.
- Citation F0689. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  CMS lists it as corrected on April 4, 2024.
- Citation F0908. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Keep all essential equipment working safely.
  CMS lists it as corrected on April 4, 2024.
- Citation F0584. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on April 4, 2024.
- Citation F0684. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  CMS lists it as corrected on April 4, 2024.
- Citation F0686. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  CMS lists it as corrected on April 4, 2024.
- Citation F0688. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  CMS lists it as corrected on April 4, 2024.
- Citation F0801. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
  CMS lists it as corrected on April 4, 2024.
- Citation F0880. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on April 4, 2024.
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CMS update of January 31, 2024
- Star rating
  The CMS staffing star rating changed from 4 of 5 to 3 of 5.
- Staffing
  Total nurse staffing reported to CMS went from 5.0 to 4.2 hours per resident per day.
41 citations
Health inspection on January 26, 2024
CMS lists this as a standard inspection and a complaint inspection.
- Citation F0550. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  CMS lists it as corrected on February 23, 2024.
- Citation F0552. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.
  CMS lists it as corrected on February 23, 2024.
- Citation F0578. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 23, 2024.
- Citation F0604. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  CMS lists it as corrected on February 23, 2024.
- Citation F0656. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on February 23, 2024.
- Citation F0658. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.
  CMS lists it as corrected on February 23, 2024.
- Citation F0684. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  CMS lists it as corrected on February 23, 2024.
- Citation F0694. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide for the safe, appropriate administration of IV fluids for a resident when needed.
  CMS lists it as corrected on February 23, 2024.
- Citation F0697. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.
  CMS lists it as corrected on February 23, 2024.
- Citation F0745. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide medically-related social services to help each resident achieve the highest possible quality of life.
  CMS lists it as corrected on February 23, 2024.
- Citation F0755. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on February 23, 2024.
- Citation F0756. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  CMS lists it as corrected on February 23, 2024.
- Citation F0757. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.
  CMS lists it as corrected on February 23, 2024.
- Citation F0758. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 23, 2024.
- Citation F0760. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that residents are free from significant medication errors.
  CMS lists it as corrected on February 23, 2024.
- Citation F0761. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 23, 2024.
- Citation F0812. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  CMS lists it as corrected on February 23, 2024.
- Citation F0849. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 23, 2024.
- Citation F0880. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on February 23, 2024.
- Citation F0553. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Allow resident to participate in the development and implementation of his or her person-centered plan of care.
  CMS lists it as corrected on February 23, 2024.
- Citation F0558. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.
  CMS lists it as corrected on February 23, 2024.
- Citation F0600. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  CMS lists it as corrected on February 23, 2024.
- Citation F0610. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Respond appropriately to all alleged violations.
  CMS lists it as corrected on February 23, 2024.
- Citation F0623. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  CMS lists it as corrected on February 23, 2024.
- Citation F0625. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 23, 2024.
- Citation F0655. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  CMS lists it as corrected on February 23, 2024.
- Citation F0657. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  CMS lists it as corrected on February 23, 2024.
- Citation F0660. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Plan the resident's discharge to meet the resident's goals and needs.
  CMS lists it as corrected on February 23, 2024.
- Citation F0678. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  CMS lists it as corrected on February 23, 2024.
- Citation F0685. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Assist a resident in gaining access to vision and hearing services.
  CMS lists it as corrected on February 23, 2024.
- Citation F0686. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  CMS lists it as corrected on February 23, 2024.
- Citation F0690. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  CMS lists it as corrected on February 23, 2024.
- Citation F0693. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 23, 2024.
- Citation F0698. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.
  CMS lists it as corrected on February 23, 2024.
- Citation F0791. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide or obtain dental services for each resident.
  CMS lists it as corrected on February 23, 2024.
- Citation F0809. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on February 23, 2024.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on February 23, 2024.
- Citation F0908. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Keep all essential equipment working safely.
  CMS lists it as corrected on February 23, 2024.
- Citation F0637. Severity B: potential for minimal harm, pattern.
  The rule CMS cited: Assess the resident when there is a significant change in condition
  CMS lists it as corrected on February 23, 2024.
- Citation F0640. Severity B: potential for minimal harm, pattern.
  The rule CMS cited: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  CMS lists it as corrected on February 23, 2024.
- Citation F0641. Severity B: potential for minimal harm, pattern.
  The rule CMS cited: Ensure each resident receives an accurate assessment.
  CMS lists it as corrected on February 23, 2024.
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19 citations
Fire safety inspection on January 26, 2024
CMS lists this as a standard inspection.
- Citation K0111. Severity F: potential for more than minimal harm, widespread.
  The rule CMS cited: Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
  CMS lists it as corrected on February 29, 2024.
- Citation K0918. Severity F: potential for more than minimal harm, widespread.
  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.
  CMS lists it as corrected on February 29, 2024.
- Citation K0223. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
  CMS lists it as corrected on February 29, 2024.
- Citation K0291. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.
  CMS lists it as corrected on February 29, 2024.
- Citation K0353. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.
  CMS lists it as corrected on February 29, 2024.
- Citation K0362. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
  CMS lists it as corrected on February 29, 2024.
- Citation K0363. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Install corridor and hallway doors that block smoke.
  CMS lists it as corrected on February 29, 2024.
- Citation K0511. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Have properly installed electrical wiring and gas equipment.
  CMS lists it as corrected on February 29, 2024.
- Citation K0912. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Have power receptacles that are properly grounded.
  CMS lists it as corrected on February 29, 2024.
- Citation K0920. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure proper usage of power strips and extension cords.
  CMS lists it as corrected on February 29, 2024.
- Citation K0321. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
  CMS lists it as corrected on February 29, 2024.
- Citation K0324. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide properly protected cooking facilities.
  CMS lists it as corrected on February 29, 2024.
- Citation K0343. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
  CMS lists it as corrected on February 29, 2024.
- Citation K0351. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Install an approved automatic sprinkler system.
  CMS lists it as corrected on February 29, 2024.
- Citation K0712. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Have simulated fire drills held at unexpected times.
  CMS lists it as corrected on February 29, 2024.
- Citation K0741. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
  CMS lists it as corrected on February 29, 2024.
- Citation K0781. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Have restrictions on the use of portable space heaters.
  CMS lists it as corrected on February 29, 2024.
- Citation K0923. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Have proper medical gas storage and administration areas.
  CMS lists it as corrected on February 29, 2024.
- Citation K0925. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that sources of ignition are removed from patients receiving respiratory therapy.
  CMS lists it as corrected on February 29, 2024.
See this home on CMS Care Compare
6 citations
Health inspection on January 11, 2024
CMS lists this as a complaint inspection.
- Citation F0686. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  CMS lists it as corrected on February 2, 2024.
- Citation F0755. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on February 2, 2024.
- Citation F0684. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  CMS lists it as corrected on February 2, 2024.
- Citation F0842. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on February 2, 2024.
- Citation F0850. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Hire a qualified full-time social worker in a facility with more than 120 beds.
  CMS lists it as corrected on February 2, 2024.
- Citation F0880. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on February 2, 2024.
See this home on CMS Care Compare
4 citations
Health inspection on November 29, 2023
CMS lists this as a complaint inspection.
- Citation F0880. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Provide and implement an infection prevention and control program.
  CMS lists it as corrected on December 12, 2023.
- Citation F0609. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  CMS lists it as corrected on December 12, 2023.
- Citation F0656. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  CMS lists it as corrected on December 12, 2023.
- Citation F0732. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Post nurse staffing information every day.
  CMS lists it as corrected on December 12, 2023.
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5 citations
Health inspection on November 7, 2023
CMS lists this as a complaint inspection.
- Citation F0803. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: 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.
  CMS lists it as corrected on December 2, 2023.
- Citation F0804. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  CMS lists it as corrected on December 2, 2023.
- Citation F0677. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.
  CMS lists it as corrected on December 2, 2023.
- Citation F0692. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.
  CMS lists it as corrected on December 2, 2023.
- Citation F0760. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that residents are free from significant medication errors.
  CMS lists it as corrected on December 2, 2023.
See this home on CMS Care Compare
3 citations
Health inspection on November 1, 2023
CMS lists this as a complaint inspection.
- Citation F0842. Severity E: potential for more than minimal harm, pattern.
  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  CMS lists it as corrected on November 16, 2023.
- Citation F0600. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  CMS lists it as corrected on November 16, 2023.
- Citation F0755. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  CMS lists it as corrected on November 16, 2023.
See this home on CMS Care Compare
3 citations
Health inspection on October 29, 2023
CMS lists this as a complaint inspection.
- Citation F0580. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  CMS lists it as corrected on November 20, 2023.
- Citation F0773. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
  CMS lists it as corrected on November 20, 2023.
- Citation F0885. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Report COVID19 data to residents and families.
  CMS lists it as corrected on November 20, 2023.
See this home on CMS Care Compare
2 citations
Health inspection on October 17, 2023
CMS lists this as a complaint inspection.
- Citation F0584. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: 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.
  CMS lists it as corrected on November 2, 2023.
- Citation F0585. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Honor 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.
  CMS lists it as corrected on November 2, 2023.
See this home on CMS Care Compare
1 citation
Health inspection on October 5, 2023
CMS lists this as a complaint inspection.
- Citation F0689. Severity D: potential for more than minimal harm, isolated.
  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  CMS lists it as corrected on October 17, 2023.
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Owners and managers

CMS lists these owners and managers for this home. Names are as CMS writes them.

JACK, SPENCEROperational/managerial control · not applicable · since 06/15/2023

Questions

When was Mirage Post Acute last inspected?

CMS lists April 24, 2026 as the date of its most recent standard health inspection.

How many citations (violations) does Mirage Post Acute have?

CMS lists 276 health citations since October 5, 2023. CMS also calls these deficiencies.

Has Mirage Post Acute been fined?

CMS lists 3 fines in the past three years, $153,991 in total.

What is the CMS star rating of Mirage Post Acute?

Its CMS overall star rating is 1 of 5.

Is Mirage Post Acute a Special Focus Facility?

Yes. CMS lists it as a Special Focus Facility candidate.

CMS star ratings

Facts from CMS

Inspections, fines and changes

CMS update of October 28, 2026

Health inspection on August 25, 2026

Health inspection on August 21, 2026

Health inspection on August 10, 2026

CMS update of July 29, 2026

Health inspection on July 1, 2026

Health inspection on June 17, 2026

Health inspection on June 13, 2026

Health inspection on June 9, 2026

Health inspection on June 2, 2026

Health inspection on May 29, 2026

Health inspection on May 22, 2026

CMS update of April 29, 2026

Health inspection on April 28, 2026

Health inspection on April 24, 2026

Fire safety inspection on April 24, 2026

Health inspection on March 6, 2026

CMS update of February 25, 2026

Health inspection on February 2, 2026

Health inspection on January 30, 2026

Health inspection on January 20, 2026

Health inspection on December 17, 2025

Health inspection on November 25, 2025

Health inspection on November 24, 2025

CMS update of November 20, 2025

Health inspection on September 5, 2025

Health inspection on August 21, 2025

Health inspection on August 7, 2025

Health inspection on July 22, 2025

July 22, 2025 (1 year ago)

Health inspection on July 15, 2025

Health inspection on July 9, 2025

CMS update of June 25, 2025

Health inspection on June 5, 2025

Health inspection on May 16, 2025

Health inspection on April 3, 2025

Health inspection on March 28, 2025

Health inspection on March 12, 2025

Health inspection on March 11, 2025

Health inspection on March 10, 2025

March 10, 2025 (1 year ago)

CMS update of February 26, 2025

Health inspection on February 25, 2025

Health inspection on February 7, 2025

February 7, 2025 (1 year ago)

Health inspection on February 4, 2025

Health inspection on January 28, 2025

Health inspection on January 22, 2025

Health inspection on January 17, 2025

Fire safety inspection on January 17, 2025

Health inspection on January 7, 2025

Health inspection on January 6, 2025

CMS update of December 20, 2024

Health inspection on December 19, 2024

Health inspection on December 12, 2024

Health inspection on December 6, 2024

Health inspection on November 25, 2024

Health inspection on November 15, 2024

Health inspection on November 14, 2024

Health inspection on November 13, 2024

CMS update of October 30, 2024

Health inspection on October 8, 2024

Health inspection on October 3, 2024

Health inspection on September 28, 2024

Health inspection on September 3, 2024

Health inspection on August 8, 2024

CMS update of July 31, 2024

Health inspection on July 11, 2024

Health inspection on May 6, 2024

Health inspection on May 1, 2024

CMS update of April 25, 2024

Health inspection on April 16, 2024

Health inspection on March 18, 2024

CMS update of January 31, 2024

Health inspection on January 26, 2024

Fire safety inspection on January 26, 2024

Health inspection on January 11, 2024