The Vardell Report.O'Connor Hospital D/P SNF

Across 3 inspections from March 2023 to August 2025, state surveyors documented 23 findings at O'Connor Hospital D/P SNF; 23 have a recorded correction; CMS lists no enforcement action in the window.

Inspections

3

2023–2025, standard

Findings

23

Deficiencies cited by state inspectors

Corrected

23

Of 23 findings, with a recorded correction date

Penalties

0

No fines or payment denials in the window

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Aug 292025

   Standard health inspection

   2 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 18, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Sep 18, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. May 202024

   Standard health inspection

   10 findings

   • F700Try 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.Level FNo actual harm, potential for moreCorrected Jun 18, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Jun 12, 2024
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jun 12, 2024
   • F688Provide 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.Level DNo actual harm, potential for moreCorrected Jun 12, 2024
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jun 12, 2024
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Jun 12, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jun 12, 2024
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 12, 2024
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected May 20, 2024
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level DNo actual harm, potential for moreCorrected Jun 12, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Mar 232023

   Standard health inspection

   11 findings

   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Apr 24, 2023
   • F865Have a plan that describes the process for conducting QAPI and QAA activities.Level ENo actual harm, potential for moreCorrected Apr 24, 2023
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Apr 24, 2023
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Apr 21, 2023
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Apr 21, 2023
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 21, 2023
   • F700Try 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.Level DNo actual harm, potential for moreCorrected Apr 24, 2023
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Apr 24, 2023
   • F758Implement 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.Level DNo actual harm, potential for moreCorrected Apr 24, 2023
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Apr 21, 2023
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel DNo actual harm, potential for moreCorrected Apr 24, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Quality of Care, Cited in Two Inspections

   Inspectors cited F684 in March 2023 and August 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232425F684 across all 3 inspections, oldest to newest
2. 2

   Citation F700, Cited in Two Inspections

   Inspectors cited F700 in March 2023 and May 2024. The agency describes it this way: 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. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232425F700 across all 3 inspections, oldest to newest
3. 3

   Pharmacy Services, Cited in Two Inspections

   Inspectors cited F755 in March 2023 and May 2024. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232425F755 across all 3 inspections, oldest to newest
4. 4

   Citation F756, Cited in Two Inspections

   Inspectors cited F756 in March 2023 and May 2024. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232425F756 across all 3 inspections, oldest to newest
5. 5

   Medication Error Rate, Cited in Two Inspections

   Inspectors cited F759 in May 2024 and August 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232425F759 across all 3 inspections, oldest to newest
6. 6

   Infection Control, Cited in Two Inspections

   Inspectors cited F880 in March 2023 and May 2024. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232425F880 across all 3 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in two inspections, most seriously at level D.

2. 02

   What changed after F700 was cited, and how do you check it now?

   Citation F700: cited in two inspections, most seriously at level F.

3. 03

   How often does the consultant pharmacist review each resident’s medications?

   Pharmacy Services: cited in two inspections, most seriously at level E.

4. 04

   What changed after F756 was cited, and how do you check it now?

   Citation F756: cited in two inspections, most seriously at level D.

5. 05

   How are medication passes checked, and what happens when an error is found?

   Medication Error Rate: cited in two inspections, most seriously at level D.

6. 06

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in two inspections, most seriously at level E.

7. 07

   How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

   No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

8. 08

   Has the home been fined or had payments denied before this record begins?

   CMS lists no fines or payment denials in this window. The record starts March 23, 2023; anything earlier is not in it.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Mar 23, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection May 20, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Aug 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 555916

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.