SANTA ANITA CONVALESCENT HOSP
Inspection History Overview
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.
Fines and Penalties by Year
2025 1 penalties totaling $21,548
Fine
2021 1 penalties totaling $32,240
Fine
2018 2 penalties totaling $124,693
Fine
Payment Denial
2017 1 penalties totaling $51,949
Fine
Health Violations by Year
2025 39 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Ensure each resident receives an accurate assessment.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure medication error rates are not 5 percent or greater.
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.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Dispose of garbage and refuse properly.
2024 60 violations
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Provide safe and appropriate respiratory care for a resident when needed.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
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.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Ensure that residents are fully informed and understand their health status, care and treatments.
Reasonably accommodate the needs and preferences of each resident.
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.
Keep residents' personal and medical records private and confidential.
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.
PASARR screening for Mental disorders or Intellectual Disabilities
2023 62 violations
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide safe and appropriate respiratory care for a resident when needed.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Allow residents to self-administer drugs if determined clinically appropriate.
Reasonably accommodate the needs and preferences of each resident.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Ensure each resident receives an accurate assessment.
2022 19 violations
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide and implement an infection prevention and control program.
Provide and implement an infection prevention and control program.
Provide and implement an infection prevention and control program.
Report COVID19 data to residents and families.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Reasonably accommodate the needs and preferences of each resident.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide safe and appropriate respiratory care for a resident when needed.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure that residents are free from significant medication errors.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide and implement an infection prevention and control program.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide and implement an infection prevention and control program.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
2021 7 violations
Provide and implement an infection prevention and control program.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Provide and implement an infection prevention and control program.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide safe and appropriate respiratory care for a resident when needed.
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Provide and implement an infection prevention and control program.
2020 9 violations
Provide and implement an infection prevention and control program.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Provide and implement an infection prevention and control program.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe, appropriate pain management for a resident who requires such services.
2019 30 violations
Reasonably accommodate the needs and preferences of each resident.
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.
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Provide safe and appropriate respiratory care for a resident when needed.
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.
Post nurse staffing information every day.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
2018 37 violations
Ensure services provided by the nursing facility meet professional standards of quality.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Allow residents to self-administer drugs if determined clinically appropriate.
Reasonably accommodate the needs and preferences of each resident.
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.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Ensure each resident receives an accurate assessment.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide safe, appropriate pain management for a resident who requires such services.
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
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.
2017 37 violations
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
Provide necessary care and services to maintain or improve the highest well being of each resident .
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Give residents a notice of rights, rules, services and charges.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Keep each resident free from physical restraints, unless needed for medical treatment.
Reasonably accommodate the needs and preferences of each resident.
Provide activities to meet the interests and needs of each resident.
Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.
Maintain comfortable sound levels.
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide necessary care and services to maintain or improve the highest well being of each resident .
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.