23 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Garden Grove, CA
4-star overall rating with 4-star inspections with 23 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
12232 Chapman Ave, Garden Grove, CA
(714) 971-5517
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
99
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Mandelbaum Family
Operator or chain grouping
Approved since
1967-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 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
RN hours / resident day
0.73
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
2.14
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.18
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
6.04
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.86
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
5.42
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
2.27
Higher values indicate more complex resident acuity
RN turnover
19%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
3,170
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9989
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7.10
Baseline 20.98% · Performance 18.14% · Measure score 7.10 · Achievement 7.10 · Improvement 6.69
Healthcare-associated infections
1.15
Baseline 8.64% · Performance 8.03% · Measure score 1.15 · Achievement 0 · Improvement 1.15
Total nurse turnover
8.44
Baseline 27.12% · Performance 29.17% · Measure score 8.44 · Achievement 8.44 · Improvement 0
Adjusted total nurse staffing
1.55
Baseline 3.81 hours · Performance 3.52 hours · Measure score 1.55 · Achievement 1.55 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.48% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 245 · Observed rate 9.39% · Lower 95% interval 8.05% |
| Discharge to community | 60.24% |
50.57%
9.7 pts better
|
Better than the National Rate · Eligible stays 234 · Observed rate 55.13% · Lower 95% interval 55.1% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 98.82% |
95.27%
3.5 pts better
|
Numerator 168 · Denominator 170 |
| Falls with major injury | 0.59% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 170 |
| Discharge self-care score | 46.3% |
53.69%
7.4 pts worse
|
Numerator 25 · Denominator 54 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 24 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 1.18% |
2.29%
1.1 pts better
|
Numerator 2 · Denominator 170 · Adjusted rate 0.85% |
| Healthcare-associated infections requiring hospitalization | 8.03% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 131 · Observed rate 9.16% · Lower 95% interval 4.77% |
| Staff COVID-19 vaccination coverage | 11.79% |
8.2%
3.6 pts better
|
Numerator 23 · Denominator 195 |
| Staff flu vaccination coverage | 55.56% |
42%
13.6 pts better
|
Numerator 110 · Denominator 198 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 27 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 114 · Denominator 114 |
| Transfer of health information to patient | 86.36% |
96.28%
9.9 pts worse
|
Numerator 19 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 20.69% |
25.2%
4.5 pts worse
|
Numerator 18 · Denominator 87 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.3
0.6 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.7 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.6
1.1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.6 · Expected 1.7 · 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 | 0.3% |
1.6%
1.3 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
6.8%
6.4 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
4.1%
2.4 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.1% · Q3 1.4% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.3% |
13.7%
4.6 pts worse
|
19.6%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 24.0% · Q3 16.0% · Q4 14.3% · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.3% |
14.2%
1.9 pts better
|
16.7%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 13.0% · Q3 13.2% · Q4 14.3% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 4.5% |
0.4%
4.1 pts worse
|
0.1%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.9% · Q3 5.1% · Q4 6.4% · 4Q avg 4.5% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.3% |
11.0%
4.3 pts worse
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.9% |
10.7%
0.8 pts better
|
14.9%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.7% · Q3 14.3% · Q4 16.7% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
1.0%
2.4 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.9% · Q3 2.1% · Q4 1.8% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.4% |
10.9%
8.5 pts better
|
19.8%
17.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 3.8% · Q4 3.8% · 4Q avg 2.4% |
| 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 6.1% · Q2 5.5% · Q3 3.5% · Q4 4.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
11.2%
3.2 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 7.9% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.5% |
1.5%
3 pts worse
|
1.6%
2.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.5% · Q3 6.2% · Q4 0.0% · 4Q avg 4.5% · 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 | 23.8% |
23.2%
0.6 pts worse
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 24.5% · Expected 24.5% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (6 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Top issue: Quality of Life and Care (7 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Top issue: Pharmacy Service (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-10
Fire Safety
Use approved construction type or materials.
Corrected 2025-01-10
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-01
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-05-24
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-05-24
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-24
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-05-24
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-24
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-05-24
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-05-24
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-05-24
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-13
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-13
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-02-13
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-13
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-13
Health
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.
Corrected 2026-02-13
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-02-13
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-02-13
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 2026-02-13
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 2026-02-13
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2026-02-13
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-02-13
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-13
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2026-02-13
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2026-02-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-13
Health
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.
Corrected 2026-02-13
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-02-13
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-02-13
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2026-02-13
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2026-02-13
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-25
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-03
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-01-03
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-03
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-01-03
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-03
Health
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.
Corrected 2025-01-03
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-03
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-01-03
Health
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.
Corrected 2025-01-03
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 2025-01-03
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 2025-01-03
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-03
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-03
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 2025-01-03
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-01-03
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-01-03
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-03
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 2025-01-03
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-03
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 2025-01-03
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-03
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-03
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 2025-01-03
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-01-03
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-10
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-06-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-01
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-06
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-06-06
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-06-06
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-06-06
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-06-06
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 2022-06-06
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 2022-06-06
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
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