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Health Inspection Summary
Sharon Care Center
8167 West Third St.
Los Angeles, CA 90048
(323) 655-2023
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Deficiency Category
Inspection Date:
6/6/24
Complaint Reporting Period:
4/1/24 - 3/31/25
Inspection Date:
2/27/22
Complaint Reporting Period:
4/1/23 - 3/31/24
Inspection Date:
7/26/19
Complaint Reporting Period:
4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies262
Quality of Life and Care Deficiencies8711
Infection Control Deficiencies063
Resident Assessment and Care Planning Deficiencies492
Nursing and Physician Services Deficiencies440
Resident Rights Deficiencies4108
Nutrition and Dietary Deficiencies332
Pharmacy Service Deficiencies533
Environmental Deficiencies212
Administration Deficiencies112

Detailed result for inspection on 6/6/24
Date of last standard health inspection:6/6/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:33
Average number of Health Deficiencies in California:16.3
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

11/26/2412/11/24
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

8/14/248/20/24
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

4/26/245/10/24
2 - Minimal harm or potential for actual harm
Few

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

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Few

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

9/25/249/27/24
2 - Minimal harm or potential for actual harm
Few

Provide enough food/fluids to maintain a resident's health.

7/11/247/15/24
2 - Minimal harm or potential for actual harm
Few

Provide enough food/fluids to maintain a resident's health.

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Few

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

10/22/2410/24/24
2 - Minimal harm or potential for actual harm
Few

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

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Few

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.

7/11/247/15/24
2 - Minimal harm or potential for actual harm
Some
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

1/14/251/16/25
2 - Minimal harm or potential for actual harm
Few

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

10/22/2410/24/24
2 - Minimal harm or potential for actual harm
Few

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

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Few

Assure that each resident’s assessment is updated at least once every 3 months.

9/25/249/27/24
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Observe each nurse aide's job performance and give regular training.

1/14/251/16/25
2 - Minimal harm or potential for actual harm
Few

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

1/14/251/16/25
2 - Minimal harm or potential for actual harm
Few

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

1/31/252/5/25
2 - Minimal harm or potential for actual harm
Few

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

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Some
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Few

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

7/11/247/15/24
2 - Minimal harm or potential for actual harm
Few

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.

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Few

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

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

1/29/251/31/25
2 - Minimal harm or potential for actual harm
Some

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

1/29/251/31/25
2 - Minimal harm or potential for actual harm
Few

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

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Few
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

1/14/251/16/25
2 - Minimal harm or potential for actual harm
Few

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.

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Few

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

4/4/244/8/24
2 - Minimal harm or potential for actual harm
Few

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.

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Few

Ensure that residents are free from significant medication errors.

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

6/6/246/14/24
1 - Potential for minimal harm
Some

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

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Few
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

6/6/246/14/24
2 - Minimal harm or potential for actual harm
Few

Detailed result for inspection on 2/27/22
Date of last standard health inspection:2/27/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24
Total number of Health Deficiencies for this nursing home:50
Average number of Health Deficiencies in California:17.3
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

3/8/243/13/24
2 - Minimal harm or potential for actual harm
Few

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

11/3/2311/17/23
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

5/4/235/19/23
2 - Minimal harm or potential for actual harm
Few

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

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

10/6/2310/30/23
4 - Immediate jeopardy to resident health or safety
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Honor each resident's preferences, choices, values and beliefs.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Some

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

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few

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.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few

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

2/27/224/24/22
3 - Actual harm
Few

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

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few

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

6/13/237/13/23
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate pain management for a resident who requires such services.

2/27/225/11/22
3 - Actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

3/1/243/20/24
2 - Minimal harm or potential for actual harm
Some

Provide and implement an infection prevention and control program.

3/1/243/20/24
2 - Minimal harm or potential for actual harm
Few

Develop and implement policies and procedures for flu and pneumonia vaccinations.

3/1/243/20/24
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Some

Develop and implement policies and procedures for flu and pneumonia vaccinations.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

2/27/225/11/22
2 - Minimal harm or potential for actual harm
Some

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

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Some

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

10/6/2310/30/23
2 - Minimal harm or potential for actual harm
Few

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

6/13/237/13/23
2 - Minimal harm or potential for actual harm
Few

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

4/24/235/11/23
2 - Minimal harm or potential for actual harm
Few

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

6/5/236/19/23
2 - Minimal harm or potential for actual harm
Few

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

7/20/238/15/23
2 - Minimal harm or potential for actual harm
Few

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

10/6/2310/30/23
3 - Actual harm
Few

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

11/3/2311/17/23
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Some

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

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Some

Post nurse staffing information every day.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

6/5/236/19/23
2 - Minimal harm or potential for actual harm
Few
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few

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

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few

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

2/27/224/24/22
3 - Actual harm
Few

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

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Some

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.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Some

Prepare residents for a safe transfer or discharge from the nursing home.

11/3/2311/17/23
2 - Minimal harm or potential for actual harm
Few

Keep residents' personal and medical records private and confidential.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

12/5/231/2/24
2 - Minimal harm or potential for actual harm
Few

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

5/10/235/25/23
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Some

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

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Some

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

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few

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.

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few

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

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

2/27/222/27/22
1 - Potential for minimal harm
Some
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

2/27/222/27/22
2 - Minimal harm or potential for actual harm
Some

Detailed result for inspection on 7/26/19
Date of last standard health inspection:7/26/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23
Total number of Health Deficiencies for this nursing home:35
Average number of Health Deficiencies in California:15.3
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

3/29/234/15/23
2 - Minimal harm or potential for actual harm
Few

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

3/29/234/15/23
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

2/24/233/16/23
2 - Minimal harm or potential for actual harm
Some

Provide safe, appropriate pain management for a resident who requires such services.

8/26/229/26/22
2 - Minimal harm or potential for actual harm
Some

Provide safe, appropriate pain management for a resident who requires such services.

5/10/225/20/22
2 - Minimal harm or potential for actual harm
Few

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.

7/26/198/19/19
2 - Minimal harm or potential for actual harm
Few

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

7/26/198/19/19
2 - Minimal harm or potential for actual harm
Some

Provide safe, appropriate pain management for a resident who requires such services.

7/26/198/19/19
2 - Minimal harm or potential for actual harm
Some

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

8/26/229/26/22
2 - Minimal harm or potential for actual harm
Some

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

7/2/228/2/22
3 - Actual harm
Few

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

6/17/227/29/22
2 - Minimal harm or potential for actual harm
Few

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

5/27/226/22/22
2 - Minimal harm or potential for actual harm
Few

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

7/8/227/19/22
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

5/27/226/22/22
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

7/26/198/19/19
2 - Minimal harm or potential for actual harm
Some

Provide and implement an infection prevention and control program.

5/22/22
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

6/18/227/19/22
2 - Minimal harm or potential for actual harm
Few

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

7/26/198/19/19
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

2/24/233/16/23
2 - Minimal harm or potential for actual harm
Few

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

5/22/22
2 - Minimal harm or potential for actual harm
Few

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

5/26/226/10/22
2 - Minimal harm or potential for actual harm
Few

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

6/8/227/18/22
2 - Minimal harm or potential for actual harm
Few

Prepare residents for a safe transfer or discharge from the nursing home.

4/13/224/24/22
2 - Minimal harm or potential for actual harm
Few

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

7/12/227/25/22
2 - Minimal harm or potential for actual harm
Few

Keep residents' personal and medical records private and confidential.

7/26/198/19/19
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

7/5/228/2/22
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

7/26/198/19/19
2 - Minimal harm or potential for actual harm
Some

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

7/26/198/19/19
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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.

6/8/227/18/22
2 - Minimal harm or potential for actual harm
Few

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

7/26/198/19/19
2 - Minimal harm or potential for actual harm
Few

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.

7/26/198/19/19
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

7/26/198/19/19
2 - Minimal harm or potential for actual harm
Few

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

7/26/198/19/19
2 - Minimal harm or potential for actual harm
Some
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

4/28/225/9/22
2 - Minimal harm or potential for actual harm
Some

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

4/19/225/15/22
2 - Minimal harm or potential for actual harm
Few
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

11/26/2412/11/24
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

8/14/248/20/24
2 - Minimal harm or potential for actual harm
Few

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

4/26/245/10/24
2 - Minimal harm or potential for actual harm
Few

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

9/25/249/27/24
2 - Minimal harm or potential for actual harm
Few

Provide enough food/fluids to maintain a resident's health.

7/11/247/15/24
2 - Minimal harm or potential for actual harm
Few

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

10/22/2410/24/24
2 - Minimal harm or potential for actual harm
Few

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.

7/11/247/15/24
2 - Minimal harm or potential for actual harm
Some

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

1/14/251/16/25
2 - Minimal harm or potential for actual harm
Few

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

10/22/2410/24/24
2 - Minimal harm or potential for actual harm
Few

Assure that each resident’s assessment is updated at least once every 3 months.

9/25/249/27/24
2 - Minimal harm or potential for actual harm
Few

Observe each nurse aide's job performance and give regular training.

1/14/251/16/25
2 - Minimal harm or potential for actual harm
Few

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

1/14/251/16/25
2 - Minimal harm or potential for actual harm
Few

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

1/31/252/5/25
2 - Minimal harm or potential for actual harm
Few

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

7/11/247/15/24
2 - Minimal harm or potential for actual harm
Few

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

1/29/251/31/25
2 - Minimal harm or potential for actual harm
Some

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

1/29/251/31/25
2 - Minimal harm or potential for actual harm
Few

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.

1/14/251/16/25
2 - Minimal harm or potential for actual harm
Few

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

4/4/244/8/24
2 - Minimal harm or potential for actual harm
Few

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

3/8/243/13/24
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

11/3/2311/17/23
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

5/4/235/19/23
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

10/6/2310/30/23
4 - Immediate jeopardy to resident health or safety
Few

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

6/13/237/13/23
2 - Minimal harm or potential for actual harm
Few

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

3/1/243/20/24
2 - Minimal harm or potential for actual harm
Some

Provide and implement an infection prevention and control program.

3/1/243/20/24
2 - Minimal harm or potential for actual harm
Few

Develop and implement policies and procedures for flu and pneumonia vaccinations.

3/1/243/20/24
2 - Minimal harm or potential for actual harm
Few

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

10/6/2310/30/23
2 - Minimal harm or potential for actual harm
Few

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

6/13/237/13/23
2 - Minimal harm or potential for actual harm
Few

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

4/24/235/11/23
2 - Minimal harm or potential for actual harm
Few

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

6/5/236/19/23
2 - Minimal harm or potential for actual harm
Few

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

7/20/238/15/23
2 - Minimal harm or potential for actual harm
Few

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

10/6/2310/30/23
3 - Actual harm
Few

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

11/3/2311/17/23
2 - Minimal harm or potential for actual harm
Few

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

6/5/236/19/23
2 - Minimal harm or potential for actual harm
Few

Prepare residents for a safe transfer or discharge from the nursing home.

11/3/2311/17/23
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

12/5/231/2/24
2 - Minimal harm or potential for actual harm
Few

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

5/10/235/25/23
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

3/29/234/15/23
2 - Minimal harm or potential for actual harm
Few

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

3/29/234/15/23
2 - Minimal harm or potential for actual harm
Few

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.

2/24/233/16/23
2 - Minimal harm or potential for actual harm
Some

Provide safe, appropriate pain management for a resident who requires such services.

8/26/229/26/22
2 - Minimal harm or potential for actual harm
Some

Provide safe, appropriate pain management for a resident who requires such services.

5/10/225/20/22
2 - Minimal harm or potential for actual harm
Few

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

8/26/229/26/22
2 - Minimal harm or potential for actual harm
Some

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

7/2/228/2/22
3 - Actual harm
Few

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

6/17/227/29/22
2 - Minimal harm or potential for actual harm
Few

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

5/27/226/22/22
2 - Minimal harm or potential for actual harm
Few

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

7/8/227/19/22
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

5/27/226/22/22
2 - Minimal harm or potential for actual harm
Few

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

6/18/227/19/22
2 - Minimal harm or potential for actual harm
Few

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.

2/24/233/16/23
2 - Minimal harm or potential for actual harm
Few

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

5/26/226/10/22
2 - Minimal harm or potential for actual harm
Few

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

6/8/227/18/22
2 - Minimal harm or potential for actual harm
Few

Prepare residents for a safe transfer or discharge from the nursing home.

4/13/224/24/22
2 - Minimal harm or potential for actual harm
Few

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

7/12/227/25/22
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

7/5/228/2/22
2 - Minimal harm or potential for actual harm
Few

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.

6/8/227/18/22
2 - Minimal harm or potential for actual harm
Few

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

4/28/225/9/22
2 - Minimal harm or potential for actual harm
Some

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

4/19/225/15/22
2 - Minimal harm or potential for actual harm
Few
Infection control inspection deficiencies in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

5/22/22
2 - Minimal harm or potential for actual harm
Some

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

5/22/22
2 - Minimal harm or potential for actual harm
Few
Medicare
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