Cycle 1
Health 2025-05-13 · Fire 2025-05-13
28 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Santa Ana, CA
Citrus Post-Acute
2-star overall rating with 2-star inspections with 28 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1929 N. Fairview Street, Santa Ana, CA
(714) 554-9700
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
144
Certified beds
Average residents
135
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Links Healthcare Group
Operator or chain grouping
Approved since
1978-08-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
31 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
0.28
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.47
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.28
CMS adjusted RN staffing hours
Adjusted total hours
3.85
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,468
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9843
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.13% · Performance 26.51% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.93
Baseline 9.39% · Performance 7.44% · Measure score 3.93 · Achievement 1.32 · Improvement 3.93
Total nurse turnover
4.27
Baseline 56.20% · Performance 46.21% · Measure score 4.27 · Achievement 4.27 · Improvement 2.69
Adjusted total nurse staffing
2.46
Baseline 3.35 hours · Performance 3.78 hours · Measure score 2.46 · Achievement 2.46 · Improvement 1.28
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.64% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 105 · Observed rate 18.1% · Lower 95% interval 9.36% |
| Discharge to community | 38.54% |
50.57%
12 pts worse
|
Worse than the National Rate · Eligible stays 84 · Observed rate 30.95% · Lower 95% interval 27.56% |
| Medicare spending per beneficiary | 1.31 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 96.8% |
95.27%
1.5 pts better
|
Numerator 121 · Denominator 125 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 125 |
| Discharge self-care score | 50.85% |
53.69%
2.8 pts worse
|
Numerator 30 · Denominator 59 |
| Discharge mobility score | 52.54% |
50.94%
1.6 pts better
|
Numerator 31 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 2.4% |
2.29%
0.1 pts worse
|
Numerator 3 · Denominator 125 · Adjusted rate 2.01% |
| Healthcare-associated infections requiring hospitalization | 7.44% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 8.93% · Lower 95% interval 4.14% |
| Staff COVID-19 vaccination coverage | 4.76% |
8.2%
3.4 pts worse
|
Numerator 7 · Denominator 147 |
| Staff flu vaccination coverage | 26.71% |
42%
15.3 pts worse
|
Numerator 43 · Denominator 161 |
| Discharge function score | 50.85% |
56.45%
5.6 pts worse
|
Numerator 30 · Denominator 59 |
| Transfer of health information to provider | 98.04% |
95.95%
2.1 pts better
|
Numerator 50 · Denominator 51 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 24.32% |
25.2%
0.9 pts worse
|
Numerator 18 · Denominator 74 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.6 |
2.3
1.3 pts worse
|
1.9
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 6.1 · Expected 3.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.4 · Expected 2.1 · 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 | 1.2% |
1.6%
0.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.9% · Q4 1.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
6.8%
6 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
4.1%
1 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.4% · Q3 1.0% · Q4 4.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.4% |
13.7%
5.3 pts better
|
19.6%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 9.3% · Q3 7.8% · Q4 6.7% · 4Q avg 8.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.7% |
14.2%
5.5 pts better
|
16.7%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 10.0% · Q3 6.5% · Q4 8.8% · 4Q avg 8.7% · 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 | 8.3% |
11.0%
2.7 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 7.5% · Q3 10.5% · Q4 0.0% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
10.7%
3.6 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 7.8% · Q3 8.4% · Q4 3.6% · 4Q avg 7.1% · 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 1.7% · Q2 0.9% · 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 | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.4% |
10.9%
3.5 pts better
|
19.8%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 8.9% · Q3 6.0% · Q4 9.1% · 4Q avg 7.4% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.7%
0.9 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 5.4% · Q3 4.6% · Q4 2.8% · 4Q avg 3.8% · 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 | 6.6% |
11.2%
4.6 pts better
|
12.0%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.6% · Observed 7.5% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.9% · Q3 0.6% · Q4 0.0% · 4Q avg 1.0% · 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 | 25.4% |
23.2%
2.2 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 28.0% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-21 · Fire 2024-06-21
41 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-01-12 · Fire 2022-01-12
19 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-30
C · Minimal harm
2025-05-13
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-05-30
C · Minimal harm
2025-05-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-30
E · Potential for more than minimal harm
2024-06-21
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-06-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-02
D · Potential for more than minimal harm
2022-01-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-02-09
D · Potential for more than minimal harm
2022-01-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-02-09
D · Potential for more than minimal harm
2022-01-12
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 2022-02-09
D · Potential for more than minimal harm
2022-01-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-02-09
D · Potential for more than minimal harm
2022-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-09
D · Potential for more than minimal harm
2022-01-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-02-09
D · Potential for more than minimal harm
2022-01-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-02-09
D · Potential for more than minimal harm
2022-01-12
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-02-09
D · Potential for more than minimal harm
2022-01-12
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-02-09
D · Potential for more than minimal harm
2022-01-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-02-09
D · Potential for more than minimal harm
2022-01-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-02-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-26
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2025-12-02
B · Minimal harm
2025-07-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Not marked corrected
E · Potential for more than minimal harm
2025-05-13
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 2025-06-06
E · Potential for more than minimal harm
2025-05-13
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 2025-06-06
E · Potential for more than minimal harm
2025-05-13
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-05-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-13
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-05-13
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 2025-06-06
D · Potential for more than minimal harm
2025-05-13
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 2025-06-06
D · Potential for more than minimal harm
2025-05-13
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 2025-06-12
D · Potential for more than minimal harm
2025-05-13
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 2025-06-12
D · Potential for more than minimal harm
2025-05-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-13
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 2025-06-06
D · Potential for more than minimal harm
2025-05-13
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 2025-06-06
D · Potential for more than minimal harm
2025-05-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-13
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 2025-06-06
D · Potential for more than minimal harm
2025-05-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-06
B · Minimal harm
2025-05-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-12
B · Minimal harm
2025-05-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-06-06
B · Minimal harm
2025-05-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-06
B · Minimal harm
2025-05-13
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 2025-06-06
B · Minimal harm
2025-05-13
F808 · Nutrition and Dietary Deficiencies
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 2025-06-06
B · Minimal harm
2025-05-13
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 2025-06-06
B · Minimal harm
2025-05-13
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-02-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-05
D · Potential for more than minimal harm
2024-08-22
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 2024-09-14
D · Potential for more than minimal harm
2024-08-22
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-09-14
D · Potential for more than minimal harm
2024-08-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-14
E · Potential for more than minimal harm
2024-07-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-10
E · Potential for more than minimal harm
2024-06-21
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 2024-07-21
E · Potential for more than minimal harm
2024-06-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-21
E · Potential for more than minimal harm
2024-06-21
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 2024-07-21
E · Potential for more than minimal harm
2024-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-21
E · Potential for more than minimal harm
2024-06-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-21
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-21
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 2024-07-21
D · Potential for more than minimal harm
2024-06-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-21
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 2024-07-21
D · Potential for more than minimal harm
2024-06-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-21
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-21
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 2024-07-21
D · Potential for more than minimal harm
2024-06-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-21
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 2024-07-21
D · Potential for more than minimal harm
2024-06-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-21
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 2024-07-21
D · Potential for more than minimal harm
2024-06-21
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 2024-07-21
D · Potential for more than minimal harm
2024-06-21
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 2024-07-21
D · Potential for more than minimal harm
2024-06-21
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 2024-07-21
D · Potential for more than minimal harm
2024-06-21
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-06-21
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 2024-07-21
D · Potential for more than minimal harm
2024-06-21
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 2024-07-21
D · Potential for more than minimal harm
2024-06-21
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-07-21
B · Minimal harm
2024-06-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-21
B · Minimal harm
2024-06-21
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-05-10
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 2024-05-30
D · Potential for more than minimal harm
2024-05-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-10
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 2024-05-30
D · Potential for more than minimal harm
2024-04-03
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 2024-04-27
D · Potential for more than minimal harm
2024-04-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-27
D · Potential for more than minimal harm
2024-04-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-27
B · Minimal harm
2024-04-03
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-27
D · Potential for more than minimal harm
2024-02-14
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-05
D · Potential for more than minimal harm
2023-11-20
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 2023-12-20
D · Potential for more than minimal harm
2023-04-27
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 2023-05-12
D · Potential for more than minimal harm
2023-03-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-21
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 2023-04-18
E · Potential for more than minimal harm
2022-01-12
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 2022-02-07
E · Potential for more than minimal harm
2022-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-07
D · Potential for more than minimal harm
2022-01-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-02-07
D · Potential for more than minimal harm
2022-01-12
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 2022-02-07
D · Potential for more than minimal harm
2022-01-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-02-07
D · Potential for more than minimal harm
2022-01-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-02-07
D · Potential for more than minimal harm
2022-01-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-02-07
D · Potential for more than minimal harm
2022-01-12
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 2022-02-07
D · Potential for more than minimal harm
2022-01-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-02-07
D · Potential for more than minimal harm
2022-01-12
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 2022-02-07
D · Potential for more than minimal harm
2022-01-12
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 2022-02-07
D · Potential for more than minimal harm
2022-01-12
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 2022-02-07
B · Minimal harm
2022-01-12
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-02-07
Penalties and ownership
What sits behind the stars
Ownership
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Alta Gardens Care Center
Garden Grove, CA
5-star overall rating with 4-star inspections with 19 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#2
Pacific Haven Subacute And Healthcare Center
Garden Grove, CA
4-star overall rating with 3-star inspections with 21 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Garden Park Care Center
Garden Grove, CA
4-star overall rating with 3-star inspections with 16 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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