Cycle 1
Health 2025-11-19 · Fire 2025-11-19
27 health deficiencies
Top issue: Nutrition and Dietary (9 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Dana Point, CA
Capistrano Beach Care Center
2-star overall rating with 2-star inspections with 27 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
35410 Del Rey, Dana Point, CA
(949) 496-5786
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
93
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1971-12-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.31
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.98
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.65
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.06
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.25
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.66
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,145
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.21
Baseline 20.95% · Performance 19.02% · Measure score 5.21 · Achievement 5.21 · Improvement 4.44
Healthcare-associated infections
0
Baseline 8.57% · Performance 8.45% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.65
Baseline 48.65% · Performance 44.68% · Measure score 4.65 · Achievement 4.65 · Improvement 1.17
Adjusted total nurse staffing
0
Baseline 3.29 hours · Performance 3.10 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.93% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 164 · Observed rate 12.2% · Lower 95% interval 8.21% |
| Discharge to community | 56.57% |
50.57%
6 pts better
|
No Different than the National Rate · Eligible stays 136 · Observed rate 53.68% · Lower 95% interval 49.83% |
| Medicare spending per beneficiary | 1.35 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 97.25% |
95.27%
2 pts better
|
Numerator 177 · Denominator 182 |
| Falls with major injury | 1.1% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 182 |
| Discharge self-care score | 58.54% |
53.69%
4.9 pts better
|
Numerator 48 · Denominator 82 |
| Discharge mobility score | 59.76% |
50.94%
8.8 pts better
|
Numerator 49 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 1.1% |
2.29%
1.2 pts better
|
Numerator 2 · Denominator 182 · Adjusted rate 0.77% |
| Healthcare-associated infections requiring hospitalization | 8.45% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 130 · Observed rate 10% · Lower 95% interval 4.72% |
| Staff COVID-19 vaccination coverage | 6.76% |
8.2%
1.4 pts worse
|
Numerator 10 · Denominator 148 |
| Staff flu vaccination coverage | 56.95% |
42%
15 pts better
|
Numerator 86 · Denominator 151 |
| Discharge function score | 65.85% |
56.45%
9.4 pts better
|
Numerator 54 · Denominator 82 |
| Transfer of health information to provider | 96.1% |
95.95%
0.1 pts better
|
Numerator 74 · Denominator 77 |
| Transfer of health information to patient | 96.23% |
96.28%
About the same
|
Numerator 51 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 31.96% |
25.2%
6.8 pts better
|
Numerator 31 · Denominator 97 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.3
0.5 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.7 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.6
0.6 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
1.6%
1.5 pts worse
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 3.2% · Q4 6.5% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.4% |
6.8%
3.6 pts worse
|
11.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 10.3% · Q3 7.1% · Q4 15.8% · 4Q avg 10.4% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
4.1%
0.6 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.6% · Q3 3.4% · Q4 5.8% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
13.7%
0.6 pts worse
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 7.7% · Q3 19.4% · Q4 18.0% · 4Q avg 14.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.0% |
14.2%
9.2 pts better
|
16.7%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 9.8% · Q3 2.3% · Q4 4.2% · 4Q avg 5.0% · 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 | 6.2% |
11.0%
4.8 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 3.8% · Q3 9.5% · Q4 3.5% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
10.7%
3.7 pts worse
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 12.3% · Q3 7.4% · Q4 20.4% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.2%
0.8 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.9% |
10.9%
6 pts better
|
19.8%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 3.3% · Q3 7.5% · Q4 0.0% · 4Q avg 4.9% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
4.7%
2 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 4.7% · Q3 2.2% · Q4 2.4% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
94.0%
5.8 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.3% |
11.2%
5.1 pts worse
|
12.0%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 15.5% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 0.0% · Q4 1.1% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.0% |
23.2%
0.2 pts better
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 22.5% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-20 · Fire 2024-09-20
31 health deficiencies
Top issue: Resident Rights (9 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-12-09 · Fire 2021-12-09
26 health deficiencies
Top issue: Nutrition and Dietary (8 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-08
F · Potential for more than minimal harm
2025-11-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-01-08
F · Potential for more than minimal harm
2025-11-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-08
E · Potential for more than minimal harm
2025-11-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-01-08
E · Potential for more than minimal harm
2025-11-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-11-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-08
C · Minimal harm
2025-11-19
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2026-01-08
F · Potential for more than minimal harm
2024-09-20
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-09-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-09-20
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-09-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-09-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-09-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-09-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-20
K224 · Egress Deficiencies
Fire Safety
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-23
E · Potential for more than minimal harm
2021-12-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-01-11
E · Potential for more than minimal harm
2021-12-09
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-01-11
E · Potential for more than minimal harm
2021-12-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-01-11
E · Potential for more than minimal harm
2021-12-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-01-11
E · Potential for more than minimal harm
2021-12-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-01-11
Inspection history
Recent health citations
E · 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 2025-12-19
E · Potential for more than minimal harm
2025-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-19
E · Potential for more than minimal harm
2025-11-19
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-12-19
E · Potential for more than minimal harm
2025-11-19
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-12-19
D · Potential for more than 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 2025-12-19
D · Potential for more than minimal harm
2025-11-19
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-12-19
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 2025-12-19
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 2025-12-19
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 2025-12-19
D · Potential for more than minimal harm
2025-11-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-19
D · Potential for more than 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 2025-12-19
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 2025-12-19
D · Potential for more than minimal harm
2025-11-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-19
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 2025-12-19
D · Potential for more than minimal harm
2025-11-19
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-11-19
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-12-19
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 2025-12-19
D · Potential for more than minimal harm
2025-11-19
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-11-19
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 2025-12-19
D · Potential for more than minimal harm
2025-11-19
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-12-19
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 2025-12-19
D · Potential for more than minimal harm
2025-11-19
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-11-19
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-12-19
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 2025-12-19
B · Minimal harm
2025-09-11
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 2025-10-11
D · Potential for more than minimal harm
2025-05-29
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-28
D · Potential for more than minimal harm
2025-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-28
D · Potential for more than minimal harm
2025-01-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-23
D · Potential for more than minimal harm
2025-01-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-15
B · Minimal harm
2025-01-16
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-02-15
E · Potential for more than minimal harm
2024-09-20
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 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
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 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
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 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
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 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
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 2024-10-20
D · Potential for more than minimal harm
2024-09-20
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 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
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 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-20
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-10-20
B · Minimal harm
2024-09-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-20
B · Minimal harm
2024-09-20
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-10-20
B · Minimal harm
2024-07-22
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2024-08-21
B · Minimal harm
2024-07-03
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.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-04-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-02-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-03-29
D · Potential for more than minimal harm
2023-12-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-27
D · Potential for more than minimal harm
2023-08-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-16
D · Potential for more than minimal harm
2023-07-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-08-06
D · Potential for more than minimal harm
2023-07-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-06
D · Potential for more than minimal harm
2023-05-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-05-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-05-05
F · Potential for more than minimal harm
2021-12-09
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2022-01-06
F · Potential for more than minimal harm
2021-12-09
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 2022-01-06
F · Potential for more than minimal harm
2021-12-09
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 2022-01-06
D · Potential for more than minimal harm
2021-12-09
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-01-06
D · Potential for more than minimal harm
2021-12-09
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 2022-01-06
D · Potential for more than minimal harm
2021-12-09
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 2022-01-06
D · Potential for more than minimal harm
2021-12-09
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 2022-01-06
D · Potential for more than minimal harm
2021-12-09
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 2022-01-06
D · Potential for more than minimal harm
2021-12-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-01-06
D · Potential for more than minimal harm
2021-12-09
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2022-01-06
D · Potential for more than minimal harm
2021-12-09
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 2022-01-06
D · Potential for more than minimal harm
2021-12-09
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-01-06
D · Potential for more than minimal harm
2021-12-09
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 2022-01-06
D · Potential for more than minimal harm
2021-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-06
D · Potential for more than minimal harm
2021-12-09
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-01-06
Penalties and ownership
What sits behind the stars
Ownership
Cbh Ops, LLC
5% Or Greater Direct Ownership Interest · Organization
Frankel, Moishe
5% Or Greater Indirect Ownership Interest · Individual
Levy, David
5% Or Greater Indirect Ownership Interest · Individual
Melliti, Rush
5% Or Greater Direct Ownership Interest · Individual
Pease, Nathan
5% Or Greater Direct Ownership Interest · Individual
Frankel, Moishe
Corporate Officer · Individual
Frankel, Moishe
W-2 Managing Employee · Individual
Levy, David
Corporate Officer · Individual
Melliti, Rush
Corporate Officer · Individual
Pease, Nathan
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
San Juan Hills Healthcare Center
San Juan Capistrano, CA
4-star overall rating with 3-star inspections with $3,174 in total fines with 28 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Orchards Skilled Nursing
Ladera Ranch, CA
5-star overall rating with 4-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Palm Terrace Healthcare & Rehabilitation Center
Laguna Hills, CA
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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