Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

EL CENTRO POST-ACUTE CARE

EL CENTRO, CA · 123 certified beds · Last Life Safety survey September 12, 2024

CMS Certification Number 555158 · first certified October 1983

Ownership

Operated by BAYSHIRE SENIOR COMMUNITIES · For profit - Limited Liability company

  • Ownership changed May 1, 2021 (change of ownership)from CONTINUUM HEALTH INC
23
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
5
Tags cited more than once
Across separate surveys
12
Inspection & testing records
Of the citations on file

Position within CA

23 citations — more than 63% of the 1,165 certified nursing homes in CA. Compared within CA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 9 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Past the typical window (September 2025 to March 2026). Most CA facilities have been surveyed by February 2027. This facility’s last Life Safety survey was September 2024. Facilities in CA are typically surveyed 12–18 months after the last one (median 14), measured over 1,766 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

6 of the 23 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0584 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.

How that compares

Citations on file over three years

Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.

This facility23CA median19National median11
Citations on file over three years, compared
MeasureCitations
This facility23
Median facility in CA19
Median facility nationally11

Survey history

Citations at each Life Safety survey
82019-0962021-0592024-09
Citations at each Life Safety survey
Survey dateCitations
September 26, 20198
May 6, 20216
September 12, 20249

Most-cited tags

Most-cited tags at this facility
K-03633K-09232E-00392K-03532K-03472E-00261K-09181E-00041
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0363Install corridor and hallway doors that block smoke.32024-09-12
K-0923Have proper medical gas storage and administration areas.22021-05-06
E-0039Conduct testing and exercise requirements.22024-09-12
K-0353Inspect, test, and maintain automatic sprinkler systems.22024-09-12
K-0347Properly provide smoke detection systems in areas open to corridors.22024-09-12
E-0026Establish roles under a Waiver declared by secretary.12024-09-12
K-0918Have generator or other power source capable of supplying service within 10 seconds.12021-05-06
E-0004Develop and maintain an Emergency Preparedness Program (EP).12021-05-06

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 10
  • Emergency Preparedness Deficiencies 6
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Construction Deficiencies 1
  • Other 2
Citations by CMS category
CategoryCitations
Smoke Deficiencies10
Emergency Preparedness Deficiencies6
Gas, Vacuum, and Electrical Systems Deficiencies4
Construction Deficiencies1
Miscellaneous Deficiencies1
Egress Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

September 12, 2024 — 9 citations

Citations issued on September 12, 2024
TagWhat the surveyor checksStatus
E-0026Establish roles under a Waiver declared by secretary.Deficient, Provider has date of correction (October 2, 2024)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (October 2, 2024)
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (October 2, 2024)
K-0347Properly provide smoke detection systems in areas open to corridors.Deficient, Provider has date of correction (October 2, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 2, 2024)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (October 2, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (October 2, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (October 2, 2024)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (October 2, 2024)

May 6, 2021 — 6 citations

Citations issued on May 6, 2021
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (June 7, 2021)
E-0041Implement emergency and standby power systems.Deficient, Provider has date of correction (June 7, 2021)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (June 7, 2021)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (June 7, 2021)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (June 7, 2021)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (June 7, 2021)

September 26, 2019 — 8 citations

Citations issued on September 26, 2019
TagWhat the surveyor checksStatus
E-0006Conduct risk assessment and an All-Hazards approach.Deficient, Provider has date of correction (November 22, 2019)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (November 22, 2019)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (November 22, 2019)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (November 22, 2019)
K-0347Properly provide smoke detection systems in areas open to corridors.Deficient, Provider has date of correction (November 22, 2019)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (November 22, 2019)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (November 22, 2019)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (November 22, 2019)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.