Cycle 1
Health 2025-04-25 · Fire 2025-04-25
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Pacific Grove, CA
Forest Hill Manor Health Center
3-star overall rating with 3-star inspections with $11,423 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
551 Gibson Avenue, Pacific Grove, CA
(831) 657-5200
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
26
Certified beds
Average residents
22
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bvhc, LLC
Operator or chain grouping
Approved since
2010-09-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 4 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
1.14
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.50
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.77
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.42
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.65
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.57
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.73
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
4.44
CMS adjusted total nurse staffing hours
Case-mix index
1.67
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.00% · Performance 23.71% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.01% · Performance 9.27% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.66% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 301 · Observed rate 8.31% · Lower 95% interval 7.1% |
| Discharge to community | 64.78% |
50.57%
14.2 pts better
|
Better than the National Rate · Eligible stays 329 · Observed rate 58.97% · Lower 95% interval 58.93% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 232 · Denominator 232 |
| Falls with major injury | 0.86% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 232 |
| Discharge self-care score | 46.96% |
53.69%
6.7 pts worse
|
Numerator 54 · Denominator 115 |
| Discharge mobility score | 48.7% |
50.94%
2.2 pts worse
|
Numerator 56 · Denominator 115 |
| Pressure ulcers or injuries, new or worsened | 1.29% |
2.29%
1 pts better
|
Numerator 3 · Denominator 232 · Adjusted rate 1.36% |
| Healthcare-associated infections requiring hospitalization | 9.27% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 221 · Observed rate 9.95% · Lower 95% interval 6.44% |
| Staff COVID-19 vaccination coverage | 15.91% |
8.2%
7.7 pts better
|
Numerator 7 · Denominator 44 |
| Staff flu vaccination coverage | 44.68% |
42%
2.7 pts better
|
Numerator 21 · Denominator 47 |
| Discharge function score | 48.7% |
56.45%
7.8 pts worse
|
Numerator 56 · Denominator 115 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 174 · Denominator 174 |
| Transfer of health information to patient | 67.24% |
96.28%
29 pts worse
|
Numerator 39 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 27.35% |
25.2%
2.2 pts better
|
Numerator 32 · Denominator 117 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 9.9% |
11.2%
1.3 pts better
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 8.9% · Expected 10.0% · 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 0.0% · Q3 1.0% · Q4 1.0% · 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 | 30.4% |
23.2%
7.2 pts worse
|
23.9%
6.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.4% · Observed 27.4% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-23 · Fire 2024-01-23
12 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
22 fire-safety deficiencies
Top issue: Emergency Preparedness (9 deficiencies)
Cycle 3
Health 2022-08-05 · Fire 2022-08-05
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-15
F · Potential for more than minimal harm
2025-04-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-15
F · Potential for more than minimal harm
2024-01-23
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-03-05
E · Potential for more than minimal harm
2024-01-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-23
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-03-05
D · Potential for more than minimal harm
2022-08-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-08-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-17
Inspection history
Recent health citations
G · Actual harm
2025-10-01
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 2025-10-20
F · Potential for more than minimal harm
2025-04-25
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 2025-05-15
E · Potential for more than minimal harm
2025-04-25
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 2025-05-15
E · Potential for more than minimal harm
2025-04-25
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 2025-05-15
D · Potential for more than minimal harm
2025-04-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-15
F · Potential for more than minimal harm
2024-01-23
F700 · Quality of Life and Care Deficiencies
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 2024-02-09
F · Potential for more than minimal harm
2024-01-23
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 2024-02-09
E · Potential for more than minimal harm
2024-01-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-09
E · Potential for more than minimal harm
2024-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-23
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 2024-02-09
D · Potential for more than minimal harm
2024-01-23
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-23
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 2024-02-09
D · Potential for more than minimal harm
2024-01-23
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 2024-02-09
D · Potential for more than minimal harm
2024-01-23
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 2024-02-09
D · Potential for more than minimal harm
2024-01-23
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 2024-02-09
E · Potential for more than minimal harm
2022-08-05
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 2022-09-04
E · Potential for more than minimal harm
2022-08-05
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 2022-09-04
E · Potential for more than minimal harm
2022-08-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-04
D · Potential for more than minimal harm
2022-08-05
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-09-04
D · Potential for more than minimal harm
2022-08-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-04
D · Potential for more than minimal harm
2022-08-05
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 2022-09-04
D · Potential for more than minimal harm
2022-08-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-04
D · Potential for more than minimal harm
2022-08-05
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 2022-09-04
Penalties and ownership
What sits behind the stars
$8,278
2025-10-01
Fine
Fine · fine $8,278
Fine
$3,145
2023-06-12
Fine
Fine · fine $3,145
Fine
Ownership
Bvhc, LLC
5% Or Greater Direct Ownership Interest · Organization
Boehrer, Bryan
5% Or Greater Indirect Ownership Interest · Individual
Martin, Richard
5% Or Greater Indirect Ownership Interest · Individual
Boehrer, Bryan
Corporate Officer · Individual
Martin, Richard
Corporate Officer · Individual
Martin, Richard
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Canterbury Woods
Pacific Grove, CA
5-star overall rating with 4-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Oceanview Post Acute
Pacific Grove, CA
3-star overall rating with 3-star inspections with $9,440 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Cypress Ridge Care Center
Monterey, CA
4-star overall rating with 3-star inspections with 14 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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