A list of the most recent deficiencies for Santa Anita Convalescent Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-13 | 2024-03-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-05 | 2024-03-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-27 | 2024-02-24 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-09 | 2024-02-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-08 | 2024-01-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-08 | 2024-01-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-27 | 2024-01-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-06 | 2024-01-05 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-11-15 | 2023-12-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-15 | 2023-12-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-15 | 2023-12-11 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-15 | 2023-12-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-13 | 2023-10-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-06 | 2023-10-30 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-09-25 | 2023-10-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-22 | 2023-10-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-09-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-01 | 2023-08-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-01 | 2023-08-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-01 | 2023-08-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-30 | 2023-07-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-17 | 2023-06-17 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-17 | 2023-06-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-17 | 2023-06-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-17 | 2023-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-17 | 2023-06-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-17 | 2023-06-17 | N |
| Post nurse staffing information every day. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-17 | 2023-06-17 | N |
| 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. | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-17 | 2023-06-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-05-17 | 2023-06-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-17 | 2023-06-17 | N |
| Dispose of garbage and refuse properly. | Health | 2023-05-17 | 2023-06-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-17 | 2023-06-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-05-17 | 2023-06-17 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-05-17 | 2023-06-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-17 | 2023-06-17 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-05-07 | 2023-05-24 | Y |
| 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. | Health | 2023-05-07 | 2023-05-24 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-19 | 2023-05-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-10 | 2023-05-09 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-10 | 2023-05-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-10 | 2023-05-09 | Y |
| 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. | Health | 2023-03-30 | 2023-04-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-22 | 2023-04-25 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-22 | 2023-04-25 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-03-10 | 2023-04-24 | Y |
| 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. | Health | 2023-03-17 | 2023-04-14 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-03-17 | 2023-04-14 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-09 | 2023-04-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-09 | 2023-04-04 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-03-08 | 2023-03-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-07 | 2023-03-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-19 | 2023-02-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-08 | 2023-02-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-27 | 2023-01-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-14 | 2023-01-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-06 | 2023-01-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-15 | 2022-11-30 | Y |
| Report COVID19 data to residents and families. | Health | 2022-10-15 | 2022-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-08 | 2022-11-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-28 | 2022-10-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-28 | 2022-10-28 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-14 | 2022-10-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-23 | 2022-09-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-05 | 2022-08-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-22 | 2022-07-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-22 | 2022-07-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-12 | 2022-06-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-14 | 2022-05-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-12 | 2022-04-14 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-15 | 2022-04-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-11 | 2022-03-23 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-07 | 2022-03-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-19 | 2021-11-08 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-05-13 | 2021-06-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-07 | 2021-04-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-26 | 2019-10-24 | N |
| 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. | Health | 2019-09-26 | 2019-10-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-26 | 2019-10-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-26 | 2019-10-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-26 | 2019-10-24 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-09-26 | 2019-10-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-26 | 2019-10-24 | N |
| 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. | Health | 2019-09-26 | 2019-10-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-26 | 2019-10-24 | N |
| 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. | Health | 2019-09-26 | 2019-10-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-26 | 2019-10-24 | N |
| 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. | Health | 2019-09-26 | 2019-10-24 | N |
| Post nurse staffing information every day. | Health | 2019-09-26 | 2019-10-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-26 | 2019-10-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-26 | 2019-10-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-26 | 2019-10-24 | N |
| 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. | Health | 2019-09-26 | 2019-10-24 | N |
| 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. | Health | 2019-09-26 | 2019-10-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-26 | 2019-10-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-26 | 2019-10-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-26 | 2019-10-24 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-09-26 | 2019-10-24 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-09-27 | 2019-10-22 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-09-27 | 2019-10-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-02 | 2018-11-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-10-02 | 2018-11-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-10-02 | 2018-11-15 | N |
| 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. | Health | 2018-10-02 | 2018-11-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-10-02 | 2018-11-15 | N |
| 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. | Health | 2018-10-02 | 2018-11-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-10-02 | 2018-11-15 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-10-02 | 2018-11-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-02 | 2018-11-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-10-02 | 2018-11-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-02 | 2018-11-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-10-02 | 2018-11-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-02 | 2018-11-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-02 | 2018-11-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-10-02 | 2018-11-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-02 | 2018-11-15 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-10-02 | 2018-11-15 | N |
| 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. | Health | 2018-10-02 | 2018-11-15 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2018-10-02 | 2018-11-15 | N |
| 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. | Health | 2018-10-02 | 2018-11-15 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-10-02 | 2018-11-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-10-02 | 2018-11-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-02 | 2018-11-15 | N |
| Dispose of garbage and refuse properly. | Health | 2018-10-02 | 2018-11-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-02 | 2018-11-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-10-02 | 2018-11-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-02 | 2018-11-15 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-10-02 | 2018-11-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-10-02 | 2018-11-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-10-22 | 2018-11-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-10-22 | 2018-11-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-10-22 | 2018-11-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-10-22 | 2018-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-22 | 2018-11-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-10-22 | 2018-11-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-22 | 2018-11-14 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2018-10-22 | 2018-11-14 | N |
