Cycle 1
Health 2025-11-19 · Fire 2025-11-19
30 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Los Alamitos, CA
Alamitos West Health & Rehabilitation
3-star overall rating with 3-star inspections with 30 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
3902 Katella Avenue, Los Alamitos, CA
(562) 596-5561
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
135
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1978-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.34
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.27
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.89
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
4.01
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
8,234
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.56% · Performance 26.55% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.29
Baseline 6.77% · Performance 6.85% · Measure score 3.29 · Achievement 3.29 · Improvement 0
Total nurse turnover
4.29
Baseline 39.67% · Performance 46.15% · Measure score 4.29 · Achievement 4.29 · Improvement 0
Adjusted total nurse staffing
3.39
Baseline 3.97 hours · Performance 4.04 hours · Measure score 3.39 · Achievement 3.39 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.71% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 373 · Observed rate 9.38% · Lower 95% interval 8.61% |
| Discharge to community | 61.06% |
50.57%
10.5 pts better
|
Better than the National Rate · Eligible stays 347 · Observed rate 55.91% · Lower 95% interval 55.35% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.68% |
95.27%
3.4 pts better
|
Numerator 225 · Denominator 228 |
| Falls with major injury | 0.44% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 228 |
| Discharge self-care score | 31.41% |
53.69%
22.3 pts worse
|
Numerator 49 · Denominator 156 |
| Discharge mobility score | 29.49% |
50.94%
21.4 pts worse
|
Numerator 46 · Denominator 156 |
| Pressure ulcers or injuries, new or worsened | 2.19% |
2.29%
0.1 pts better
|
Numerator 5 · Denominator 228 · Adjusted rate 2% |
| Healthcare-associated infections requiring hospitalization | 6.85% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 201 · Observed rate 5.97% · Lower 95% interval 4.08% |
| Staff COVID-19 vaccination coverage | 22.92% |
8.2%
14.7 pts better
|
Numerator 33 · Denominator 144 |
| Staff flu vaccination coverage | 60.65% |
42%
18.6 pts better
|
Numerator 94 · Denominator 155 |
| Discharge function score | 24.36% |
56.45%
32.1 pts worse
|
Numerator 38 · Denominator 156 |
| Transfer of health information to provider | 96.55% |
95.95%
0.6 pts better
|
Numerator 56 · Denominator 58 |
| Transfer of health information to patient | 99.18% |
96.28%
2.9 pts better
|
Numerator 121 · Denominator 122 |
| Resident COVID-19 vaccinations up to date | 33.03% |
25.2%
7.8 pts better
|
Numerator 36 · Denominator 109 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.3
About the same
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
98.5%
0.2 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 97.8% · Q4 97.8% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
98.2%
0.8 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
1.6%
1.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
6.8%
4.2 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 7.2% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
4.1%
1.1 pts worse
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 7.7% · Q3 2.9% · Q4 6.8% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.9% |
13.7%
7.8 pts better
|
19.6%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 6.2% · Q3 7.8% · Q4 6.5% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.2% |
14.2%
4 pts better
|
16.7%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 10.9% · Q3 13.2% · Q4 7.0% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.5% |
11.0%
9.5 pts worse
|
16.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 14.3% · Q3 19.3% · Q4 17.6% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
10.7%
7.5 pts worse
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 8.3% · Q3 27.9% · Q4 33.3% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.0%
0.1 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.1% · Q3 0.9% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
1.2%
1.6 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.2% · Q3 2.4% · Q4 2.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.9% |
10.9%
17 pts worse
|
19.8%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 35.7% · Q3 20.6% · Q4 35.5% · 4Q avg 27.9% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.7%
0.1 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 4.4% · Q3 3.8% · Q4 2.7% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.3% |
94.0%
18.7 pts worse
|
81.7%
6.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 73.3% · Q2 73.5% · Q3 78.0% · Q4 75.8% · 4Q avg 75.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.6% |
11.2%
4.6 pts better
|
12.0%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.6% · Observed 6.3% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.0% · Q3 0.9% · Q4 1.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.8% |
93.2%
18.4 pts worse
|
79.7%
4.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
23.2%
1.5 pts worse
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 25.2% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-27 · Fire 2024-09-27
33 health deficiencies
Top issue: Pharmacy Service (8 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-02-22 · Fire 2022-02-22
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-11-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-11-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-11-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-11-19
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-11-19
F · Potential for more than minimal harm
2024-09-27
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-27
D · Potential for more than minimal harm
2022-02-22
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-03-18
D · Potential for more than minimal harm
2022-02-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-03-18
D · Potential for more than minimal harm
2022-02-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-03-18
D · Potential for more than minimal harm
2022-02-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-18
D · Potential for more than minimal harm
2022-02-22
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-03-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-19
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-19
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-19
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-19
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-10
B · Minimal harm
2025-11-19
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-12-10
B · Minimal harm
2025-11-19
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2025-12-10
B · Minimal harm
2025-11-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-10
B · Minimal harm
2025-11-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-12-10
B · Minimal harm
2025-11-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-10
B · Minimal harm
2025-11-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-10
B · Minimal harm
2025-11-19
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-12-10
B · Minimal harm
2025-08-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
B · Minimal harm
2025-08-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Not marked corrected
B · Minimal harm
2025-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
B · Minimal harm
2025-08-22
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Not marked corrected
D · Potential for more than minimal harm
2025-07-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-04-03
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2025-04-16
B · Minimal harm
2025-04-03
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-04-16
B · Minimal harm
2025-04-03
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-01-24
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-01-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-19
B · Minimal harm
2025-01-24
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-19
D · Potential for more than minimal harm
2024-12-12
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-01-08
B · Minimal harm
2024-12-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-08
B · Minimal harm
2024-12-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-08
B · Minimal harm
2024-12-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-08
B · Minimal harm
2024-12-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-11-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-29
B · Minimal harm
2024-11-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-09-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-27
E · Potential for more than minimal harm
2024-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F849 · Administration Deficiencies
Health
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.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-09-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-10-27
C · Minimal harm
2024-09-27
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-10-27
B · Minimal harm
2024-09-27
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-10-27
B · Minimal harm
2024-09-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-27
E · Potential for more than minimal harm
2022-02-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-17
E · Potential for more than minimal harm
2022-02-22
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-22
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-22
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-22
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-22
F849 · Administration Deficiencies
Health
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.
Corrected 2022-03-17
B · Minimal harm
2022-02-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-03-17
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare South LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Ayele, Etsegenet
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Cluff, Casey
Operational/Managerial Control · Individual
Looper, William
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Willits, Adam
Corporate Director · Individual
Willits, Adam
Corporate Officer · Individual
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Seal Beach Health And Rehabilitation Center
Seal Beach, CA
1-star overall rating with 1-star inspections with $3,145 in total fines with 31 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Anaheim Point
Anaheim, CA
1-star overall rating with 1-star inspections with $16,143 in total fines with 21 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Park Anaheim Healthcare Center
Anaheim, CA
2-star overall rating with 2-star inspections with 32 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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