28 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Anaheim, CA
4-star overall rating with 3-star inspections with 28 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1135 Leisure Court, Anaheim, CA
(714) 772-1353
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
115
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Mandelbaum Family
Operator or chain grouping
Approved since
1992-09-15
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
0.36
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.86
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.21
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.88
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
727
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.78
Composite VBP score used to determine payment impact.
Payment multiplier
1.0192
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
8.85
Baseline 17.73% · Performance 17.33% · Measure score 8.85 · Achievement 8.85 · Improvement 5.23
Healthcare-associated infections
5.56
Baseline 9.79% · Performance 6.88% · Measure score 5.56 · Achievement 3.18 · Improvement 5.56
Total nurse turnover
6.20
Baseline 29.81% · Performance 38.33% · Measure score 6.20 · Achievement 6.20 · Improvement 0
Adjusted total nurse staffing
5.29
Baseline 4.09 hours · Performance 4.58 hours · Measure score 5.29 · Achievement 5.29 · Improvement 2.41
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.13% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 251 · Observed rate 6.37% · Lower 95% interval 8.04% |
| Discharge to community | 59.64% |
50.57%
9.1 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 38.66% · Lower 95% interval 45.3% |
| Medicare spending per beneficiary | 1.37 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 99.4% |
95.27%
4.1 pts better
|
Numerator 165 · Denominator 166 |
| Falls with major injury | 0.6% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 166 |
| Discharge self-care score | 87.6% |
53.69%
33.9 pts better
|
Numerator 113 · Denominator 129 |
| Discharge mobility score | 74.42% |
50.94%
23.5 pts better
|
Numerator 96 · Denominator 129 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 166 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.88% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 159 · Observed rate 3.77% · Lower 95% interval 3.88% |
| Staff COVID-19 vaccination coverage | 19.7% |
8.2%
11.5 pts better
|
Numerator 26 · Denominator 132 |
| Staff flu vaccination coverage | 71.26% |
42%
29.3 pts better
|
Numerator 119 · Denominator 167 |
| Discharge function score | 81.4% |
56.45%
25 pts better
|
Numerator 105 · Denominator 129 |
| Transfer of health information to provider | 89.19% |
95.95%
6.8 pts worse
|
Numerator 33 · Denominator 37 |
| Transfer of health information to patient | 96.67% |
96.28%
0.4 pts better
|
Numerator 29 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 60.27% |
25.2%
35.1 pts better
|
Numerator 44 · Denominator 73 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
2.3
1.1 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.6 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · 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 | 1.5% |
1.6%
0.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 1.0% · Q4 0.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
6.8%
2.8 pts better
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 10.0% · Q4 5.6% · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.1%
0.7 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 5.6% · Q3 4.9% · Q4 2.2% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.6% |
13.7%
0.1 pts better
|
19.6%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 11.9% · Q3 14.9% · Q4 14.6% · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 60.5% |
14.2%
46.3 pts worse
|
16.7%
43.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 62.5% · Q2 67.3% · Q3 54.4% · Q4 58.6% · 4Q avg 60.5% · 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 | 6.4% |
11.0%
4.6 pts better
|
16.3%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 4.3% · Q3 8.6% · Q4 3.9% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.6% |
10.7%
11.9 pts worse
|
14.9%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 19.0% · Q3 25.0% · Q4 21.4% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.0%
0.1 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.6% · Q3 0.8% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.2%
0.2 pts worse
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 3.7% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.7% |
10.9%
3.2 pts better
|
19.8%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.6% · Q3 15.6% · Q4 6.1% · 4Q avg 7.7% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
4.7%
1.2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 4.8% · Q3 3.9% · Q4 3.8% · 4Q avg 3.5% · 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 | 5.5% |
11.2%
5.7 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 6.1% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.7% |
1.5%
6.2 pts worse
|
1.6%
6.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.3% |
93.2%
2.1 pts better
|
79.7%
15.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.5% |
23.2%
9.7 pts better
|
23.9%
10.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 11.6% · Expected 20.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-02-19
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-19
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-19
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-19
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-02-19
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-19
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-19
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-02-19
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-09
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-05-09
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-05-09
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-05-09
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-01-28
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-01-28
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-27
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-27
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-02-27
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-02-27
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-27
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-02-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-27
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 2025-02-27
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-27
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 2025-02-27
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-27
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-27
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 2025-02-27
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-27
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 2025-02-27
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-02-27
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-02-27
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-02-27
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 2025-02-27
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-27
Health
Keep all essential equipment working safely.
Corrected 2025-02-27
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 2025-02-27
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 2025-02-27
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-02-27
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-21
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-05-20
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-05-20
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-05-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-20
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 2022-05-20
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-05-20
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-20
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 2022-05-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-01-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-01-17
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2020-01-17
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-01-17
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2020-01-17
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 2020-01-17
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 2020-01-17
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
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Nearby options
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